Provider Demographics
NPI:1336405406
Name:HANSEN, JILL L (MS, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:L
Last Name:HANSEN
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 MAGNAVOX WAY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1565
Mailing Address - Country:US
Mailing Address - Phone:260-483-7207
Mailing Address - Fax:260-483-0836
Practice Address - Street 1:1415 MAGNAVOX WAY
Practice Address - Street 2:SUITE 120
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1565
Practice Address - Country:US
Practice Address - Phone:260-483-7207
Practice Address - Fax:260-483-0836
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001645A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist