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General NPI Number Information
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NPI Number | 1528212669
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Entity Type | Individual
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Provider Name | JILL CORINE NICOLINO PSY.D
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Gender | Female
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Dates
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Enumeration Date | 11/14/2008
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Last Update Date | 04/25/2016
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Provider Practice Location Address
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Address Line | 4475 US 1 S STE. 609
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32086-7284
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Country | US
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Telephone | 828-242-9553
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Fax | 904-342-5467
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Provider Business Mailing Address
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Address Line | 74 COQUINA AVE
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32080-4529
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Country | US
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Telephone | 828-242-9553
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 3990
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 8278
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License Number State | FL
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