Provider Demographics
NPI:1952662504
Name:BRANTLEY, JILL CHANDLER
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:CHANDLER
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JILL
Other - Middle Name:ELIZABETH
Other - Last Name:CHANDLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8915 SW CENTER ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6307
Mailing Address - Country:US
Mailing Address - Phone:503-726-3960
Mailing Address - Fax:
Practice Address - Street 1:510 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4402
Practice Address - Country:US
Practice Address - Phone:971-369-7866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17413225700000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist