Healthcare Provider Details

I. General information

NPI: 1285118885
Provider Name (Legal Business Name): JILL WHEELER LPC, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3136 9TH ST
BOULDER CO
80304-2520
US

IV. Provider business mailing address

3980 N BROADWAY STE 103 #188
BOULDER CO
80304
US

V. Phone/Fax

Practice location:
  • Phone: 239-595-3199
  • Fax:
Mailing address:
  • Phone: 239-595-3199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number15002
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3730
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: