Provider Demographics
NPI:1770602872
Name:MAXEY, JILL WALTER (MS LPC)
Entity type:Individual
Prefix:MS
First Name:JILL
Middle Name:WALTER
Last Name:MAXEY
Suffix:
Gender:F
Credentials:MS LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 N. 6TH STREET
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-4718
Mailing Address - Country:US
Mailing Address - Phone:715-848-5022
Mailing Address - Fax:888-778-6750
Practice Address - Street 1:901 N. 6TH STREET
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-4718
Practice Address - Country:US
Practice Address - Phone:715-848-5022
Practice Address - Fax:888-778-6750
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2778-125101YM0800X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40922500Medicaid