Healthcare Provider Details

I. General information

NPI: 1154793669
Provider Name (Legal Business Name): JILISSA COPELAND LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2015
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

552 VALE PARK RD STE A
VALPARAISO IN
46385-2508
US

IV. Provider business mailing address

679 CROSS MEADOWS DR
VALPARAISO IN
46385-8847
US

V. Phone/Fax

Practice location:
  • Phone: 219-246-8873
  • Fax:
Mailing address:
  • Phone: 219-246-8873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34008560A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: