Provider Demographics
NPI:1497385785
Name:BOMSTAD, JILL RENAE (LCPC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:RENAE
Last Name:BOMSTAD
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2516 W HARBAUER LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-3449
Mailing Address - Country:US
Mailing Address - Phone:217-816-3048
Mailing Address - Fax:
Practice Address - Street 1:5850 6TH STREET FRONTAGE RD E STE A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5194
Practice Address - Country:US
Practice Address - Phone:217-529-5046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-25
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180011696101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional