Provider Demographics
NPI:1407979735
Name:DAVIS, JILL B (MA)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:B
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 WENTWORTH DR
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-9733
Mailing Address - Country:US
Mailing Address - Phone:802-878-4990
Mailing Address - Fax:802-878-1477
Practice Address - Street 1:25 WENTWORTH DR
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-9733
Practice Address - Country:US
Practice Address - Phone:802-878-4990
Practice Address - Fax:802-878-1477
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068-0000241101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007564Medicaid