Provider Demographics
NPI:1912423013
Name:MARSHALL, JILLIAN M (BCBA)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:M
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:300 INTERNATIONAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5028
Mailing Address - Country:US
Mailing Address - Phone:866-610-0580
Mailing Address - Fax:407-588-6294
Practice Address - Street 1:115 N PARK TRL STE 101
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7373
Practice Address - Country:US
Practice Address - Phone:470-491-2050
Practice Address - Fax:470-408-2371
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid