MEDICARE: MRS. JILL MARIE GOLDSWORTHY LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	18024	MN
2	1041C0700X	Clinical Social Worker	2005041020	MO
3	1041C0700X	Clinical Social Worker	7336-123	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	39-1850832	OTHER	WI	FEDERAL TAX ID

General Provider Information

NPI Number	:	1003916149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JILL MARIE GOLDSWORTHY LCSW

Provider Business Mailing Address
First Line	:	8008 GINA DR
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53406-2510
Country	:	US
Telephone Number	:	608-347-2776
Fax Number	:

Provider Business Practice Location Address
First Line	:	10045 W LISBON AVE
Second Line	:	SUITE 221
City	:	WAUWATOSA
State	:	WI
Zip	:	53222-2446
Country	:	US
Telephone Number	:	414-358-7146
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	12/08/2021

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Directions to “ MRS. JILL MARIE GOLDSWORTHY LCSW” Practice Location

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