Provider Demographics
NPI:1073169587
Name:FORMAN, JILLIAN LOUISE
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:LOUISE
Last Name:FORMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 W UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:ALFRED
Mailing Address - State:NY
Mailing Address - Zip Code:14802-1136
Mailing Address - Country:US
Mailing Address - Phone:607-281-8815
Mailing Address - Fax:
Practice Address - Street 1:2 SOUTH MAIN ST., SUITE 3
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:NY
Practice Address - Zip Code:14806
Practice Address - Country:US
Practice Address - Phone:607-281-8815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009608-01101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional