Provider Demographics
NPI:1295533024
Name:TILLIS, NICOLE JEAN
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:JEAN
Last Name:TILLIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2612 FLINT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-2115
Mailing Address - Country:US
Mailing Address - Phone:408-421-1444
Mailing Address - Fax:
Practice Address - Street 1:1671 THE ALAMEDA STE 306
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-2222
Practice Address - Country:US
Practice Address - Phone:650-690-1451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker