Provider Demographics
NPI:1275786659
Name:RUROEDE, JILLIAN (LCSW)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:RUROEDE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:GREENPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11944-1500
Mailing Address - Country:US
Mailing Address - Phone:631-477-1950
Mailing Address - Fax:631-477-2164
Practice Address - Street 1:720 FRONT ST
Practice Address - Street 2:
Practice Address - City:GREENPORT
Practice Address - State:NY
Practice Address - Zip Code:11944-1500
Practice Address - Country:US
Practice Address - Phone:631-477-1950
Practice Address - Fax:631-477-2164
Is Sole Proprietor?:No
Enumeration Date:2008-10-29
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0788521041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00659412Medicaid