Healthcare Provider Details

I. General information

NPI: 1871807685
Provider Name (Legal Business Name): JILL V MCNUTT LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7646 N TEUTONIA AVE
BROWN DEER WI
53209-1736
US

IV. Provider business mailing address

7651 N TEUTONIA AVE
BROWN DEER WI
53209-1735
US

V. Phone/Fax

Practice location:
  • Phone: 414-797-2155
  • Fax:
Mailing address:
  • Phone: 414-213-3979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number3943-125
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3943-125
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3943-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: