Provider Demographics
NPI:1649259136
Name:THEWLIS, JILL (MA,PCC,LCDCIII)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:THEWLIS
Suffix:
Gender:F
Credentials:MA,PCC,LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 CLEVELAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1805
Mailing Address - Country:US
Mailing Address - Phone:330-455-0374
Mailing Address - Fax:330-455-2101
Practice Address - Street 1:876 AMHERST RD NE
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-8528
Practice Address - Country:US
Practice Address - Phone:330-833-8516
Practice Address - Fax:330-830-3395
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH051017101YA0400X
OHE2393101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional