Provider Demographics
NPI:1982821534
Name:LATONICK-FLORES, JILL E
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:E
Last Name:LATONICK-FLORES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 EAGLE LOOKOUT DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78733-3158
Mailing Address - Country:US
Mailing Address - Phone:361-575-8217
Mailing Address - Fax:512-949-4920
Practice Address - Street 1:120 DAVID WADE DRIVE
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77902-2666
Practice Address - Country:US
Practice Address - Phone:361-575-8217
Practice Address - Fax:512-949-4920
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11894101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112748201Medicaid
TX095604701Medicaid
TX095604702Medicaid