Provider Demographics
NPI:1497477145
Name:MOEDE, JILLAH (RBT)
Entity Type:Individual
Prefix:
First Name:JILLAH
Middle Name:
Last Name:MOEDE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1462 SOLERA TER UNIT 624
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-4420
Mailing Address - Country:US
Mailing Address - Phone:770-910-4049
Mailing Address - Fax:
Practice Address - Street 1:8011 PHILIPS HWY STE 10
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7459
Practice Address - Country:US
Practice Address - Phone:904-928-0112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-22-235103106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician