Provider Demographics
NPI:1104851534
Name:TIEDEMANN, JILL M (LPCC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:M
Last Name:TIEDEMANN
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601A SAINT MICHAELS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7614
Mailing Address - Country:US
Mailing Address - Phone:505-954-8777
Mailing Address - Fax:505-954-8793
Practice Address - Street 1:1601A SAINT MICHAELS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7614
Practice Address - Country:US
Practice Address - Phone:505-954-8777
Practice Address - Fax:505-954-8793
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT3476101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM600536OtherVALUE OPTIONS