Healthcare Provider Details

I. General information

NPI: 1720121973
Provider Name (Legal Business Name): JILL SUZANNE HARTWIG BA CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2704 N MAIN ST
ROCKFORD IL
61103
US

IV. Provider business mailing address

5035 LINDEN RD
ROCKFORD IL
61109-5840
US

V. Phone/Fax

Practice location:
  • Phone: 815-968-9300
  • Fax:
Mailing address:
  • Phone: 815-560-2399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: