Provider Demographics
NPI:1568604379
Name:ILAGAN, JILL CRYSTAL PAYNE (PSYD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:CRYSTAL PAYNE
Last Name:ILAGAN
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 1:1041 JOHNNIE DODDS BLVD
Mailing Address - Street 2:SUITE 5C
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-6156
Mailing Address - Country:US
Mailing Address - Phone:843-693-9650
Mailing Address - Fax:
Practice Address - Street 1:1041 JOHNNIE DODDS BLVD
Practice Address - Street 2:SUITE 5C
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-6156
Practice Address - Country:US
Practice Address - Phone:843-693-9650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-26
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1067103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical