Healthcare Provider Details

I. General information

NPI: 1972816114
Provider Name (Legal Business Name): JACQUELINE GILLILAND MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 07/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 S KIRKWOOD RD SUITE 200
KIRKWOOD MO
63122-6195
US

IV. Provider business mailing address

343 S KIRKWOOD RD SUITE 200
KIRKWOOD MO
63122-6195
US

V. Phone/Fax

Practice location:
  • Phone: 314-729-4005
  • Fax: 314-729-4002
Mailing address:
  • Phone: 314-729-4005
  • Fax: 314-729-4002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number003635
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: