MEDICARE: JILL CRUNKLETON

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	CSW007364	GA

General Provider Information

NPI Number	:	1154082824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILL CRUNKLETON

Provider Business Mailing Address
First Line	:	PO BOX 766
Second Line	:
City	:	SAUTEE NACOOCHEE
State	:	GA
Zip	:	30571-0766
Country	:	US
Telephone Number	:	706-963-0983
Fax Number	:

Provider Business Practice Location Address
First Line	:	154 LAUREL RIDGE RD
Second Line	:
City	:	CLEVELAND
State	:	GA
Zip	:	30528-2418
Country	:	US
Telephone Number	:	706-963-0983
Fax Number	:

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

Provider Enumeration Date	:	01/05/2022
Last Update Date	:	01/05/2022

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