Provider Demographics
NPI:1154483071
Name:JILLSON, DAPHYNE JOY (MA LPC CACIII)
Entity Type:Individual
Prefix:MS
First Name:DAPHYNE
Middle Name:JOY
Last Name:JILLSON
Suffix:
Gender:F
Credentials:MA LPC CACIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 CLUB MANOR DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008
Mailing Address - Country:US
Mailing Address - Phone:719-595-7728
Mailing Address - Fax:719-584-4808
Practice Address - Street 1:56 CLUB MANOR DR
Practice Address - Street 2:SUITE 100
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008
Practice Address - Country:US
Practice Address - Phone:719-595-7728
Practice Address - Fax:719-584-4808
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3789101YA0400X
CO1375101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health