Provider Demographics
NPI:1790042596
Name:KOLSTAD, JILL (MED)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:KOLSTAD
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6205 FALLOW CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-3544
Mailing Address - Country:US
Mailing Address - Phone:903-724-9985
Mailing Address - Fax:817-423-0787
Practice Address - Street 1:6205 FALLOW CT
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3544
Practice Address - Country:US
Practice Address - Phone:903-724-9985
Practice Address - Fax:817-423-0787
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX495743101YM0800X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health