Provider Demographics
NPI:1154082824
Name:CRUNKLETON, JILL
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:CRUNKLETON
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:PO BOX 766
Mailing Address - Street 2:
Mailing Address - City:SAUTEE NACOOCHEE
Mailing Address - State:GA
Mailing Address - Zip Code:30571-0766
Mailing Address - Country:US
Mailing Address - Phone:706-963-0983
Mailing Address - Fax:
Practice Address - Street 1:154 LAUREL RIDGE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:GA
Practice Address - Zip Code:30528-2418
Practice Address - Country:US
Practice Address - Phone:706-963-0983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0073641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical