=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508271461
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JILLIAN STERNER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2014
-----------------------------------------------------
Last Update Date | 06/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1798 MAEVE CIR
-----------------------------------------------------
City | WEST MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32904-7350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-223-7070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1798 MAEVE CIR
-----------------------------------------------------
City | WEST MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32904-7350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-223-7070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MFT CONTRACTOR
-----------------------------------------------------
Name | JILLIAN STERNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 321-223-7070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | IMT 2116
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------