Provider Demographics
NPI:1083104442
Name:AXELROD, JILLEN B (PHD)
Entity Type:Individual
Prefix:
First Name:JILLEN
Middle Name:B
Last Name:AXELROD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 5TH AVE APT 1D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-7604
Mailing Address - Country:US
Mailing Address - Phone:212-505-1963
Mailing Address - Fax:
Practice Address - Street 1:96 5TH AVE APT 1D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-7604
Practice Address - Country:US
Practice Address - Phone:212-505-1963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-11
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006539103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty