Provider Demographics
NPI:1083902662
Name:TILLEY, JENNIFER L (PLPC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:TILLEY
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 COUNTY ROAD 5110
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MO
Mailing Address - Zip Code:65560-8292
Mailing Address - Country:US
Mailing Address - Phone:573-247-3804
Mailing Address - Fax:
Practice Address - Street 1:1048 COUNTY ROAD 5110
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MO
Practice Address - Zip Code:65560-8292
Practice Address - Country:US
Practice Address - Phone:573-247-3804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-15
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011038140101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional