Provider Demographics
NPI:1770702524
Name:BOTTRELL, JIL DIANE (PHD)
Entity type:Individual
Prefix:
First Name:JIL
Middle Name:DIANE
Last Name:BOTTRELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4054 TEAL AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3520
Mailing Address - Country:US
Mailing Address - Phone:907-479-4177
Mailing Address - Fax:
Practice Address - Street 1:600 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3643
Practice Address - Country:US
Practice Address - Phone:907-457-4177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK176103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral