Healthcare Provider Details

I. General information

NPI: 1417179409
Provider Name (Legal Business Name): JILL ELIZABETH SULLIVAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 06/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 EAST ERIE, SUITE 355
CHICAGO IL
60611
US

IV. Provider business mailing address

1 E ERIE ST SUITE 355
CHICAGO IL
60611-2740
US

V. Phone/Fax

Practice location:
  • Phone: 312-642-2330
  • Fax:
Mailing address:
  • Phone: 312-642-2330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number071006133
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: