Provider Demographics
NPI:1598106445
Name:FISHBURN, JILL D (LAC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:D
Last Name:FISHBURN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3603 N 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3638
Mailing Address - Country:US
Mailing Address - Phone:602-206-1911
Mailing Address - Fax:602-396-2525
Practice Address - Street 1:3603 N 7TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3638
Practice Address - Country:US
Practice Address - Phone:602-206-1911
Practice Address - Fax:602-396-2525
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC - 13630101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health