Provider Demographics
NPI:1780562066
Name:SOUTHWELL, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:SOUTHWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 E 34TH ST APT 1519
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-9840
Mailing Address - Country:US
Mailing Address - Phone:716-951-2764
Mailing Address - Fax:
Practice Address - Street 1:222 E 34TH ST APT 1519
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-9840
Practice Address - Country:US
Practice Address - Phone:716-951-2764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-25
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1767495231103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool