Healthcare Provider Details

I. General information

NPI: 1376205344
Provider Name (Legal Business Name): MRS. JILLIAN COLETTE FREEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1734 W SHAW AVE
FRESNO CA
93711-3486
US

IV. Provider business mailing address

1734 W SHAW AVE
FRESNO CA
93711-3486
US

V. Phone/Fax

Practice location:
  • Phone: 559-439-2647
  • Fax: 559-439-2214
Mailing address:
  • Phone: 559-439-2647
  • Fax: 559-439-2214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAMFT127118
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: