Provider Demographics
NPI:1114460094
Name:BORTON, JILL EVELYN (MA LLP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:EVELYN
Last Name:BORTON
Suffix:
Gender:F
Credentials:MA LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 S. LINDEN RD
Mailing Address - Street 2:STE C.
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532
Mailing Address - Country:US
Mailing Address - Phone:810-630-1152
Mailing Address - Fax:810-630-9107
Practice Address - Street 1:1309 S. LINDEN RD
Practice Address - Street 2:STE. C
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532
Practice Address - Country:US
Practice Address - Phone:810-630-1152
Practice Address - Fax:810-630-9107
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-28
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007270103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist