Provider Demographics
NPI:1093290553
Name:IDICULA, JILL ANN
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ANN
Last Name:IDICULA
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 1:1800 W BIG BEAVER RD STE 150
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-3535
Mailing Address - Country:US
Mailing Address - Phone:248-918-5600
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY PEDIATRICIANS AUTISM CENTER
Practice Address - Street 2:16700 17 MILE ROAD SUITE B
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038
Practice Address - Country:US
Practice Address - Phone:586-228-2300
Practice Address - Fax:586-228-2307
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI7401001204103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician