Provider Demographics
NPI:1619650744
Name:SALO, JILL (MS, LADC, LPCC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:SALO
Suffix:
Gender:F
Credentials:MS, LADC, LPCC
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:VAN OTTERLOO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12400 WHITEWATER DR STE 140
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-4168
Mailing Address - Country:US
Mailing Address - Phone:952-479-0640
Mailing Address - Fax:
Practice Address - Street 1:12400 WHITEWATER DR STE 140
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-4168
Practice Address - Country:US
Practice Address - Phone:952-479-0640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305949101YA0400X
MN3974101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)