Provider Demographics
NPI:1508900580
Name:RICKE, JILL L (PHD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:L
Last Name:RICKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15755
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-5755
Mailing Address - Country:US
Mailing Address - Phone:850-877-6011
Mailing Address - Fax:850-893-6013
Practice Address - Street 1:1535 KILLEARN CENTER BLVD
Practice Address - Street 2:SUITE D-1
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32309-3467
Practice Address - Country:US
Practice Address - Phone:850-877-6011
Practice Address - Fax:850-893-6013
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0004423103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73698OtherBLUE CROSS BLUE SHIELD