Provider Demographics
NPI:1174825855
Name:CONRAD, JILL/ ELLEN (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:JILL/
Middle Name:ELLEN
Last Name:CONRAD
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 BROADWAY STREET NE SUITE #409
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301
Mailing Address - Country:US
Mailing Address - Phone:503-370-8050
Mailing Address - Fax:
Practice Address - Street 1:1300 BROADWAY ST. NE
Practice Address - Street 2:STE # 409
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-9730
Practice Address - Country:US
Practice Address - Phone:503-370-8050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT0731106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist