Provider Demographics
NPI:1689103863
Name:PILLER, JACKIE BLACK (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:BLACK
Last Name:PILLER
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MEETINGHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:MA
Mailing Address - Zip Code:02056-1795
Mailing Address - Country:US
Mailing Address - Phone:617-259-0125
Mailing Address - Fax:
Practice Address - Street 1:29 FRANKLIN ST UNIT 3
Practice Address - Street 2:
Practice Address - City:WRENTHAM
Practice Address - State:MA
Practice Address - Zip Code:02093-1210
Practice Address - Country:US
Practice Address - Phone:617-644-0603
Practice Address - Fax:617-644-0163
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-09
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11989101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health