Provider Demographics
NPI:1164812533
Name:DEVINE, JILLIAN
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:DEVINE
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 1:1417 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-3310
Mailing Address - Country:US
Mailing Address - Phone:208-292-2188
Mailing Address - Fax:208-292-2189
Practice Address - Street 1:1417 N 4TH ST
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-3310
Practice Address - Country:US
Practice Address - Phone:208-292-2188
Practice Address - Fax:208-292-2189
Is Sole Proprietor?:No
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor