Healthcare Provider Details

I. General information

NPI: 1689300733
Provider Name (Legal Business Name): JILLIAN BALOG MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILLIAN GIFFORD

II. Dates (important events)

Enumeration Date: 07/29/2022
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1951 NW 7TH AVE STE 300
MIAMI FL
33136-1112
US

IV. Provider business mailing address

5685 103RD TER N
PINELLAS PARK FL
33782-2708
US

V. Phone/Fax

Practice location:
  • Phone: 305-902-6347
  • Fax:
Mailing address:
  • Phone: 727-686-3250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: