MEDICARE: JILL KOLSTAD M.ED

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	101YM0800X	Mental Health Counselor	495743	TX
2	174400000X	Specialist	495743	TX

General Provider Information

NPI Number	:	1790042596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILL KOLSTAD M.ED

Provider Business Mailing Address
First Line	:	6205 FALLOW CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-3544
Country	:	US
Telephone Number	:	903-724-9985
Fax Number	:	817-423-0787

Provider Business Practice Location Address
First Line	:	6205 FALLOW CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-3544
Country	:	US
Telephone Number	:	903-724-9985
Fax Number	:	817-423-0787

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

Provider Enumeration Date	:	04/18/2012
Last Update Date	:	04/18/2012

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