Provider Demographics
NPI:1275666935
Name:ELLINWOOD, JILL DIANE (MA, LCSW, LPC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:DIANE
Last Name:ELLINWOOD
Suffix:
Gender:F
Credentials:MA, LCSW, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S5789 S SHORE RD
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-9235
Mailing Address - Country:US
Mailing Address - Phone:608-356-7039
Mailing Address - Fax:
Practice Address - Street 1:505 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-2183
Practice Address - Country:US
Practice Address - Phone:608-355-4214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI647-125101YM0800X
WI1197-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical