Provider Demographics
NPI:1477791309
Name:IANNETTA, JILLIAN (MA)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:IANNETTA
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 1:25000 CENTER RIDGE RD
Mailing Address - Street 2:6
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-4105
Mailing Address - Country:US
Mailing Address - Phone:440-892-7034
Mailing Address - Fax:440-250-9013
Practice Address - Street 1:25000 CENTER RIDGE RD
Practice Address - Street 2:6
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-4105
Practice Address - Country:US
Practice Address - Phone:440-892-7034
Practice Address - Fax:440-250-9013
Is Sole Proprietor?:No
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0701107101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional