Provider Demographics
NPI:1831627504
Name:HILLIS, JACLYN (PSYD)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:HILLIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 NEIL AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-2333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1640 NEIL AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-2333
Practice Address - Country:US
Practice Address - Phone:614-292-5766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2017-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7438103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical