Provider Demographics
NPI:1790852325
Name:LOOMIS, JILL I (MSW, MDIV)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:I
Last Name:LOOMIS
Suffix:
Gender:F
Credentials:MSW, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 E FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-5315
Mailing Address - Country:US
Mailing Address - Phone:814-234-3464
Mailing Address - Fax:
Practice Address - Street 1:141 E FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-5315
Practice Address - Country:US
Practice Address - Phone:814-234-3464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW009100-L104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker