Basic Information
| Provider Information | |||||||||
| NPI: | 1154483071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JILLSON | ||||||||
| FirstName: | DAPHYNE | ||||||||
| MiddleName: | JOY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA LPC CACIII | ||||||||
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| Mailing Information | |||||||||
| Address1: | 56 CLUB MANOR DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195957728 | ||||||||
| FaxNumber: | 7195844808 | ||||||||
| Practice Location | |||||||||
| Address1: | 56 CLUB MANOR DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195957728 | ||||||||
| FaxNumber: | 7195844808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 3789 | CO | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 1375 | CO | X | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.