1316218944 NPI number — MS. JILLIAN ELIZABETH SAMMON LCSW

Table of content: MS. JILLIAN ELIZABETH SAMMON LCSW (NPI 1316218944)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316218944 NPI number — MS. JILLIAN ELIZABETH SAMMON LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAMMON
Provider First Name:
JILLIAN
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316218944
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 SW COLORADO AVE
Provider Second Line Business Mailing Address:
SUITE 350
Provider Business Mailing Address City Name:
BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97702-1150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-647-0514
Provider Business Mailing Address Fax Number:
541-408-9016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 SW COLORADO AVE
Provider Second Line Business Practice Location Address:
SUITE 350
Provider Business Practice Location Address City Name:
BEND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97702-1150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-647-0514
Provider Business Practice Location Address Fax Number:
541-408-9016
Provider Enumeration Date:
01/12/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  L4289 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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