Provider Demographics
NPI:1326339011
Name:LILLY, JENNIFER (MFC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LILLY
Suffix:
Gender:F
Credentials:MFC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1947 DIVISADERO ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-2532
Mailing Address - Country:US
Mailing Address - Phone:415-871-8236
Mailing Address - Fax:
Practice Address - Street 1:1947 DIVISADERO ST
Practice Address - Street 2:SUITE 3
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-2532
Practice Address - Country:US
Practice Address - Phone:415-871-8236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA090127761101YS0200X
CAMFC 52545106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool