Provider Demographics
NPI:1982912564
Name:JIVIDEN, JILL LYNN (MED,LPCC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:LYNN
Last Name:JIVIDEN
Suffix:
Gender:F
Credentials:MED,LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:853 STONEWATER DR
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-2052
Mailing Address - Country:US
Mailing Address - Phone:330-414-5652
Mailing Address - Fax:
Practice Address - Street 1:112 E MAIN ST FL 2
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-2525
Practice Address - Country:US
Practice Address - Phone:330-414-5652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-17
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0602046101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional