Provider Demographics
NPI:1902954027
Name:BLACKWELDER, JILL (LPCS, CCS, LCAS, NCC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:BLACKWELDER
Suffix:
Gender:F
Credentials:LPCS, CCS, LCAS, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 SIGNAL HILL DRIVE EXT
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-4391
Mailing Address - Country:US
Mailing Address - Phone:704-872-0234
Mailing Address - Fax:704-818-1115
Practice Address - Street 1:536 SIGNAL HILL DRIVE EXTENSION
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625
Practice Address - Country:US
Practice Address - Phone:704-872-0234
Practice Address - Fax:704-818-1115
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2135101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health