Healthcare Provider Details

I. General information

NPI: 1992223192
Provider Name (Legal Business Name): JILL MCCULLOCH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 GORDON LN
SANTA ROSA CA
95404-5636
US

IV. Provider business mailing address

300 STONY POINT RD APT 190
SANTA ROSA CA
95401-5960
US

V. Phone/Fax

Practice location:
  • Phone: 707-527-3249
  • Fax:
Mailing address:
  • Phone: 707-490-7962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: