Healthcare Provider Details

I. General information

NPI: 1982511721
Provider Name (Legal Business Name): JILLIAN L FORMAN LMHC NCC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 S MAIN ST SUITE #3
ANDOVER NY
14806
US

IV. Provider business mailing address

67 W UNIVERSITY ST
ALFRED NY
14802-1136
US

V. Phone/Fax

Practice location:
  • Phone: 607-281-8815
  • Fax:
Mailing address:
  • Phone: 607-281-8815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JILLIAN L FORMAN
Title or Position: OWNER
Credential: LMHC NCC
Phone: 607-281-8815