Provider Demographics
NPI:1265103527
Name:VANCE, JILL ROBINSON (PSYD)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:ROBINSON
Last Name:VANCE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4421 N WOLCOTT AVE APT 1A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5868
Mailing Address - Country:US
Mailing Address - Phone:440-668-1276
Mailing Address - Fax:
Practice Address - Street 1:4421 N WOLCOTT AVE APT 1A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5868
Practice Address - Country:US
Practice Address - Phone:440-668-1276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-25
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010622103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical