Provider Demographics
NPI:1972070241
Name:HUMPHREY, JILLIAN MICHAEL (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:MICHAEL
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 GOOSE POND RD
Mailing Address - Street 2:
Mailing Address - City:MORGANFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42437-5970
Mailing Address - Country:US
Mailing Address - Phone:270-285-2265
Mailing Address - Fax:
Practice Address - Street 1:452 GOOSE POND RD
Practice Address - Street 2:
Practice Address - City:MORGANFIELD
Practice Address - State:KY
Practice Address - Zip Code:42437-5970
Practice Address - Country:US
Practice Address - Phone:270-285-2265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
KY272718103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100844780Medicaid