Provider Demographics
NPI:1649748377
Name:SHAMP, JILL ELIZABETH (LICDC-CS)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:ELIZABETH
Last Name:SHAMP
Suffix:
Gender:F
Credentials:LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 LEE RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44120-5122
Mailing Address - Country:US
Mailing Address - Phone:216-417-6166
Mailing Address - Fax:
Practice Address - Street 1:3535 LEE RD
Practice Address - Street 2:
Practice Address - City:SHAKER HTS
Practice Address - State:OH
Practice Address - Zip Code:44120-5122
Practice Address - Country:US
Practice Address - Phone:216-417-6166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH862274101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)