Provider Demographics
NPI:1861903171
Name:HANSEN, JILLIAN (MED, BSL)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:HANSEN
Suffix:
Gender:F
Credentials:MED, BSL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1496 BRIAN LN
Mailing Address - Street 2:
Mailing Address - City:EFFORT
Mailing Address - State:PA
Mailing Address - Zip Code:18330-7942
Mailing Address - Country:US
Mailing Address - Phone:570-656-7484
Mailing Address - Fax:
Practice Address - Street 1:1496 BRIAN LN
Practice Address - Street 2:
Practice Address - City:EFFORT
Practice Address - State:PA
Practice Address - Zip Code:18330-7942
Practice Address - Country:US
Practice Address - Phone:570-656-7484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-14
Last Update Date:2017-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH000809103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty