Provider Demographics
NPI:1992029664
Name:WALLACE, JILL (MED,LCPC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MED,LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 ELM ST
Mailing Address - Street 2:
Mailing Address - City:TOPSHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04086-1417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:56 ELM ST
Practice Address - Street 2:
Practice Address - City:TOPSHAM
Practice Address - State:ME
Practice Address - Zip Code:04086-1417
Practice Address - Country:US
Practice Address - Phone:207-449-5729
Practice Address - Fax:866-531-8540
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC00000733101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional