Provider Demographics
NPI:1730561689
Name:RACINE, JILLIAN M (PHD)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:M
Last Name:RACINE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4505 SPICEWOOD SPRINGS RD STE 335
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8541
Mailing Address - Country:US
Mailing Address - Phone:512-467-1376
Mailing Address - Fax:512-467-8658
Practice Address - Street 1:4505 SPICEWOOD SPRINGS RD STE 335
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8541
Practice Address - Country:US
Practice Address - Phone:512-467-1376
Practice Address - Fax:512-467-8658
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-26
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
TX37220103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist