Provider Demographics
NPI:1750836102
Name:FORTAIN, JILLIAN (PHD)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:FORTAIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 S LIVERNOIS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2584
Mailing Address - Country:US
Mailing Address - Phone:248-608-8800
Mailing Address - Fax:
Practice Address - Street 1:441 S LIVERNOIS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-2584
Practice Address - Country:US
Practice Address - Phone:248-608-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016800103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist