Provider Demographics
NPI:1033622691
Name:POPPE MACKENZIE, JILL ALANE (JD, LSW)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:ALANE
Last Name:POPPE MACKENZIE
Suffix:
Gender:F
Credentials:JD, LSW
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:ALANE
Other - Last Name:POPPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:JD
Mailing Address - Street 1:628 LOXWOOD LN
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45458-6301
Mailing Address - Country:US
Mailing Address - Phone:952-240-6060
Mailing Address - Fax:
Practice Address - Street 1:955 CONGRESS PARK DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4009
Practice Address - Country:US
Practice Address - Phone:937-269-3047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1451150101YM0800X, 104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker