Provider Demographics
NPI:1184026726
Name:BORNER, JILL (LCSWR)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:BORNER
Suffix:
Gender:F
Credentials:LCSWR
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 1176
Mailing Address - Street 2:
Mailing Address - City:PORT EWEN
Mailing Address - State:NY
Mailing Address - Zip Code:12466-1176
Mailing Address - Country:US
Mailing Address - Phone:845-339-8707
Mailing Address - Fax:845-339-8740
Practice Address - Street 1:319 BROADWAY
Practice Address - Street 2:
Practice Address - City:PORT EWEN
Practice Address - State:NY
Practice Address - Zip Code:12466-5501
Practice Address - Country:US
Practice Address - Phone:845-339-8707
Practice Address - Fax:845-339-8740
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR050436-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical