=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760623938
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JIL CHIPMAN MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2009
-----------------------------------------------------
Last Update Date | 09/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 65 MAIN STREET SUITE B
-----------------------------------------------------
City | WEAVERVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-355-3081
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 477
-----------------------------------------------------
City | DOUGLAS CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96024-0477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-355-3081
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC28958
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------