Provider Demographics
NPI:1275182719
Name:MAYNARD, JILL (LPC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32500 W WAYBURN ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-2770
Mailing Address - Country:US
Mailing Address - Phone:248-821-4880
Mailing Address - Fax:
Practice Address - Street 1:42000 6 MILE RD STE 202
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48168-4374
Practice Address - Country:US
Practice Address - Phone:248-283-3703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-07
Last Update Date:2019-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISC0000129101YS0200X
MI6401007565101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool