Provider Demographics
NPI:1407425044
Name:DOLAN, JILL MARIE (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:JILL
Middle Name:MARIE
Last Name:DOLAN
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 1:4565 HARRISON ST FL 3
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60162-1617
Mailing Address - Country:US
Mailing Address - Phone:708-240-4435
Mailing Address - Fax:
Practice Address - Street 1:4565 HARRISON ST FL 3
Practice Address - Street 2:
Practice Address - City:HILLSIDE
Practice Address - State:IL
Practice Address - Zip Code:60162-1617
Practice Address - Country:US
Practice Address - Phone:708-240-4435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490175541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1801304142Medicaid