Provider Demographics
NPI:1073720876
Name:SPILLMAN, JENNIFER LEIGH (PSYD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEIGH
Last Name:SPILLMAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3067
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77305-3067
Mailing Address - Country:US
Mailing Address - Phone:936-521-6100
Mailing Address - Fax:936-760-2898
Practice Address - Street 1:233 SGT ED HOLCOMB BLVD S
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-1990
Practice Address - Country:US
Practice Address - Phone:936-521-6100
Practice Address - Fax:936-760-2898
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39115103TC0700X
TX18717101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164521003Medicaid