Provider Demographics
NPI:1134907215
Name:PROK, JILL (MSSA, E-RYT)
Entity type:Individual
Prefix:MS
First Name:JILL
Middle Name:
Last Name:PROK
Suffix:
Gender:F
Credentials:MSSA, E-RYT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 FERN CT
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45244-1442
Mailing Address - Country:US
Mailing Address - Phone:216-650-6621
Mailing Address - Fax:
Practice Address - Street 1:2600 VICTORY PKWY
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45206-1395
Practice Address - Country:US
Practice Address - Phone:513-751-7747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-19
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHS.2411660104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator