Provider Demographics
NPI:1528212669
Name:NICOLINO, JILL CORINE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:CORINE
Last Name:NICOLINO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 COQUINA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-4529
Mailing Address - Country:US
Mailing Address - Phone:828-242-9553
Mailing Address - Fax:
Practice Address - Street 1:4475 US 1 S
Practice Address - Street 2:STE. 609
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-7284
Practice Address - Country:US
Practice Address - Phone:828-242-9553
Practice Address - Fax:904-342-5467
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-14
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3990103TC0700X
FL8278103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical