Basic Information
Provider Information | |||||||||
NPI: | 1487193009 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LIGHT | ||||||||
FirstName: | JILL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.ED., LPCC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | OETZEL | ||||||||
OtherFirstName: | JILL | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 551 CINCINNATI BATAVIA PIKE | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452441518 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5137521555 | ||||||||
FaxNumber: | 9374441605 | ||||||||
Practice Location | |||||||||
Address1: | 551 CINCINNATI BATAVIA PIKE | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452441518 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5137521555 | ||||||||
FaxNumber: | 9374441605 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2017 | ||||||||
LastUpdateDate: | 07/11/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 1500151 | OH | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | E.1901290 | OH | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.