Provider Demographics
NPI:1306374145
Name:THEOBALD, JILLIAN M
Entity Type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:M
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-2929
Mailing Address - Country:US
Mailing Address - Phone:774-451-4370
Mailing Address - Fax:
Practice Address - Street 1:1061 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-6728
Practice Address - Country:US
Practice Address - Phone:508-491-6716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-24
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health