Provider Demographics
NPI:1184893539
Name:VANDENBERG, JILLIAN (MSW)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:VANDENBERG
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19506 BROWNSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CASSOPOLIS
Mailing Address - State:MI
Mailing Address - Zip Code:49031-8569
Mailing Address - Country:US
Mailing Address - Phone:574-283-1107
Mailing Address - Fax:574-283-1131
Practice Address - Street 1:403 E MADISON ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2322
Practice Address - Country:US
Practice Address - Phone:574-283-1107
Practice Address - Fax:574-283-1131
Is Sole Proprietor?:No
Enumeration Date:2008-02-29
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN6801089375104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker