Healthcare Provider Details

I. General information

NPI: 1114460094
Provider Name (Legal Business Name): JILL EVELYN BORTON MA LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 S. LINDEN RD STE. C
FLINT MI
48532
US

IV. Provider business mailing address

1309 S. LINDEN RD STE C.
FLINT MI
48532
US

V. Phone/Fax

Practice location:
  • Phone: 810-630-1152
  • Fax: 810-630-9107
Mailing address:
  • Phone: 810-630-1152
  • Fax: 810-630-9107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301007270
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: