Provider Demographics
NPI:1306013826
Name:SMITH, JILL ELIZABETH (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:ELIZABETH
Last Name:SMITH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 GETTYSBURG AVE N
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-3816
Mailing Address - Country:US
Mailing Address - Phone:763-595-9665
Mailing Address - Fax:
Practice Address - Street 1:12425 RIVER RIDGE BLVD
Practice Address - Street 2:#200
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4871
Practice Address - Country:US
Practice Address - Phone:952-562-8500
Practice Address - Fax:952-562-8501
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN137021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical