Healthcare Provider Details

I. General information

NPI: 1124670021
Provider Name (Legal Business Name): JILLIAN ELISE BELCHER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S KENTUCKY AVE STE 215
LAKELAND FL
33801-5089
US

IV. Provider business mailing address

4326 LAKE UNDERHILL RD APT D
ORLANDO FL
32803-7019
US

V. Phone/Fax

Practice location:
  • Phone: 352-708-6283
  • Fax:
Mailing address:
  • Phone: 703-409-6590
  • 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 Code106S00000X
TaxonomyBehavior Technician
License NumberA62764484
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: