Healthcare Provider Details

I. General information

NPI: 1962074823
Provider Name (Legal Business Name): JILLIAN EICHOLTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1639 FORUM PL STE 7
WEST PALM BEACH FL
33401-2330
US

IV. Provider business mailing address

9202 PINEHURST DR
BOYNTON BEACH FL
33426-5904
US

V. Phone/Fax

Practice location:
  • Phone: 561-712-8821
  • Fax:
Mailing address:
  • Phone: 135-240-3817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: