Provider Demographics
NPI:1851665939
Name:JILLSON, COLLEEN (LCSW, LADC, CCS)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:JILLSON
Suffix:
Gender:F
Credentials:LCSW, LADC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1360
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-1360
Mailing Address - Country:US
Mailing Address - Phone:207-893-0386
Mailing Address - Fax:207-893-2086
Practice Address - Street 1:86 TANDBERG TRL
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-5841
Practice Address - Country:US
Practice Address - Phone:207-893-0386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-07
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC4982101YA0400X
MELC170061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1851665939Medicaid
MEE400450569OtherMEDICARE