Healthcare Provider Details

I. General information

NPI: 1528212669
Provider Name (Legal Business Name): JILL CORINE NICOLINO PSY.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2008
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4475 US 1 S STE. 609
SAINT AUGUSTINE FL
32086-7284
US

IV. Provider business mailing address

74 COQUINA AVE
SAINT AUGUSTINE FL
32080-4529
US

V. Phone/Fax

Practice location:
  • Phone: 828-242-9553
  • Fax: 904-342-5467
Mailing address:
  • Phone: 828-242-9553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3990
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number8278
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: