Provider Demographics
NPI:1982805883
Name:COLEMAN, JILL
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:COLEMAN
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 1:321 NW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE GROVE
Mailing Address - State:IA
Mailing Address - Zip Code:50533-1308
Mailing Address - Country:US
Mailing Address - Phone:515-448-9008
Mailing Address - Fax:
Practice Address - Street 1:321 NW 3RD ST
Practice Address - Street 2:
Practice Address - City:EAGLE GROVE
Practice Address - State:IA
Practice Address - Zip Code:50533-1308
Practice Address - Country:US
Practice Address - Phone:515-448-9008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0737841Medicaid