MEDICARE: JILL BORNER LCSWR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	R050436-1	NY

General Provider Information

NPI Number	:	1184026726
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILL BORNER LCSWR

Provider Business Mailing Address
First Line	:	PO BOX 1176
Second Line	:
City	:	PORT EWEN
State	:	NY
Zip	:	12466-1176
Country	:	US
Telephone Number	:	845-339-8707
Fax Number	:	845-339-8740

Provider Business Practice Location Address
First Line	:	319 BROADWAY
Second Line	:
City	:	PORT EWEN
State	:	NY
Zip	:	12466-5501
Country	:	US
Telephone Number	:	845-339-8707
Fax Number	:	845-339-8740

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2014
Last Update Date	:	09/25/2014

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