Provider Demographics
NPI:1598782559
Name:ENTIS, JILL LORRAINE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:LORRAINE
Last Name:ENTIS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CEDAR CT
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6903
Mailing Address - Country:US
Mailing Address - Phone:802-233-0653
Mailing Address - Fax:802-879-5335
Practice Address - Street 1:5 CEDAR CT
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6903
Practice Address - Country:US
Practice Address - Phone:802-233-0653
Practice Address - Fax:802-879-5335
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
VT08900008471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN2837Medicaid
58714OtherBLUE CROSS BS VT
58714OtherBLUE CROSS BS VT