Healthcare Provider Details

I. General information

NPI: 1942165261
Provider Name (Legal Business Name): JILL WHITAKER LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

391 OLD LOCKE 3 RD
DEMOPOLIS AL
36732-5519
US

IV. Provider business mailing address

391 OLD LOCKE 3 RD
DEMOPOLIS AL
36732-5519
US

V. Phone/Fax

Practice location:
  • Phone: 334-372-3284
  • Fax:
Mailing address:
  • Phone: 334-372-3284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3753C
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: