Provider Demographics
NPI:1336496082
Name:HILLIS, JEREMY KEITH (MHC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:KEITH
Last Name:HILLIS
Suffix:
Gender:M
Credentials:MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 RESERVOIR AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-6043
Mailing Address - Country:US
Mailing Address - Phone:401-259-0340
Mailing Address - Fax:
Practice Address - Street 1:1150 RESERVOIR AVE STE 203
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6043
Practice Address - Country:US
Practice Address - Phone:401-259-0340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101YM0800X
101YM0800X
RI101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health