Healthcare Provider Details

I. General information

NPI: 1548807175
Provider Name (Legal Business Name): JILLIAN ALLIBONE SUDPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2019
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 MAIN ST
MELROSE PARK IL
60160-3902
US

IV. Provider business mailing address

11000 LAKE CITY WAY NE
SEATTLE WA
98125-6748
US

V. Phone/Fax

Practice location:
  • Phone: 708-786-8533
  • Fax:
Mailing address:
  • Phone: 206-901-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149041558
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO61021630
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: