Provider Demographics
NPI:1619019106
Name:WALCK, JILL MICHELLE (BA)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:MICHELLE
Last Name:WALCK
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 28TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-6737
Mailing Address - Country:US
Mailing Address - Phone:727-368-6271
Mailing Address - Fax:727-368-6271
Practice Address - Street 1:500 7TH AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4820
Practice Address - Country:US
Practice Address - Phone:727-767-4403
Practice Address - Fax:727-767-4715
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL766932100Medicaid