Provider Demographics
NPI:1831509850
Name:CARLSON, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:CARLSON
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 1:14300 NICOLLET CT STE 130
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-3422
Mailing Address - Country:US
Mailing Address - Phone:651-286-8527
Mailing Address - Fax:651-647-1861
Practice Address - Street 1:14300 NICOLLET CT STE 130
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-3422
Practice Address - Country:US
Practice Address - Phone:651-286-8527
Practice Address - Fax:651-647-1861
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN586101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health