Provider Demographics
NPI:1972645463
Name:NEITLICH, JILL G (MSW)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:G
Last Name:NEITLICH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:WARDSBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05355
Mailing Address - Country:US
Mailing Address - Phone:802-896-6271
Mailing Address - Fax:
Practice Address - Street 1:35 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:WARDSBORO
Practice Address - State:VT
Practice Address - Zip Code:05355
Practice Address - Country:US
Practice Address - Phone:802-896-6271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0890000600104100000X
MA107840104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT38897OtherBLUE CROSS BLUE SHIELD VT
VTOVN2189Medicaid
VTOVN2189Medicaid