Provider Demographics
NPI:1023262771
Name:BASHORUN, JILL MAREE (LPC)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MAREE
Last Name:BASHORUN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 492
Mailing Address - Street 2:
Mailing Address - City:WELLSTON
Mailing Address - State:OK
Mailing Address - Zip Code:74881-0492
Mailing Address - Country:US
Mailing Address - Phone:405-650-7278
Mailing Address - Fax:
Practice Address - Street 1:800 BIRCH STREET
Practice Address - Street 2:
Practice Address - City:WELLSTON
Practice Address - State:OK
Practice Address - Zip Code:74881
Practice Address - Country:US
Practice Address - Phone:405-356-2533
Practice Address - Fax:405-356-2838
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-07
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2206101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK736081919Medicaid