Provider Demographics
NPI:1184778847
Name:GOTTFRIED, JILL ROBIN (LIC AC)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:ROBIN
Last Name:GOTTFRIED
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 HAYNES AVE
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02540-2314
Mailing Address - Country:US
Mailing Address - Phone:508-540-1628
Mailing Address - Fax:
Practice Address - Street 1:52 HAYNES AVE
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02540-2314
Practice Address - Country:US
Practice Address - Phone:508-540-1628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA202417171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist