Provider Demographics
NPI:1154636389
Name:TIEDEMAN, JILL MARIE
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:MARIE
Last Name:TIEDEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JILL
Other - Middle Name:MARIE
Other - Last Name:SOLARI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5903 MONTAUK WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-7282
Mailing Address - Country:US
Mailing Address - Phone:209-986-3672
Mailing Address - Fax:
Practice Address - Street 1:8421 AUBURN BLVD
Practice Address - Street 2:BLDG. 3
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-0359
Practice Address - Country:US
Practice Address - Phone:916-722-6100
Practice Address - Fax:916-722-9229
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65810106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist