Healthcare Provider Details

I. General information

NPI: 1528225158
Provider Name (Legal Business Name): JILLYN M KAUFMAN LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILLYN KYARSGAARD LISW

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 12/10/2022
Certification Date: 12/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3475 JERSEY RIDGE RD STE 2
DAVENPORT IA
52807-2293
US

IV. Provider business mailing address

3475 JERSEY RIDGE RD STE 2
DAVENPORT IA
52807-2293
US

V. Phone/Fax

Practice location:
  • Phone: 319-481-3534
  • Fax: 563-213-5615
Mailing address:
  • Phone: 319-481-3534
  • Fax: 563-213-5615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.014677
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number007861
License Number StateIA

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: