Provider Demographics
NPI:1265677256
Name:FOSHOLM, JILL MARIE (MA, LPC)
Entity Type:Individual
Prefix:MISS
First Name:JILL
Middle Name:MARIE
Last Name:FOSHOLM
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12055 41ST AVE N
Mailing Address - Street 2:APT 215
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-1228
Mailing Address - Country:US
Mailing Address - Phone:612-743-4663
Mailing Address - Fax:
Practice Address - Street 1:2920 BRYANT AVE S
Practice Address - Street 2:SUITE #4
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2195
Practice Address - Country:US
Practice Address - Phone:612-743-4663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-05
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLPC00688101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional