Provider Demographics
NPI:1003466798
Name:BALLESTEROS- BOWMAN, JILL ANDREA
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:ANDREA
Last Name:BALLESTEROS- BOWMAN
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 1:3205 HELENA SPRINGS AVE APT G
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-9350
Mailing Address - Country:US
Mailing Address - Phone:323-392-2190
Mailing Address - Fax:
Practice Address - Street 1:1140 3RD ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-6274
Practice Address - Country:US
Practice Address - Phone:202-468-8823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPRC200001884101YP2500X
GALPC013744101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor