Provider Demographics
NPI:1134511876
Name:CHICIAK, JILL (ATR-BC, LPAT)
Entity type:Individual
Prefix:MS
First Name:JILL
Middle Name:
Last Name:CHICIAK
Suffix:
Gender:F
Credentials:ATR-BC, LPAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LUPTON AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-5901
Mailing Address - Country:US
Mailing Address - Phone:856-693-5775
Mailing Address - Fax:
Practice Address - Street 1:408 S WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:AUDUBON
Practice Address - State:NJ
Practice Address - Zip Code:08106-1311
Practice Address - Country:US
Practice Address - Phone:856-693-5775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-03
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ16LP00008100221700000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0996025Medicaid