Healthcare Provider Details

I. General information

NPI: 1134907215
Provider Name (Legal Business Name): JILL PROK MSSA, E-RYT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2023
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 VICTORY PKWY
CINCINNATI OH
45206-1395
US

IV. Provider business mailing address

624 FERN CT
CINCINNATI OH
45244-1442
US

V. Phone/Fax

Practice location:
  • Phone: 513-751-7747
  • Fax:
Mailing address:
  • Phone: 216-650-6621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2411660
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: