Provider Demographics
NPI:1447794680
Name:HENDERSON, JILLIAN (LCSW, LAC)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LCSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19445 TWIN LAKES RD
Mailing Address - Street 2:
Mailing Address - City:FRENCHTOWN
Mailing Address - State:MT
Mailing Address - Zip Code:59834-9711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:402 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3546
Practice Address - Country:US
Practice Address - Phone:509-575-4084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-07
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT200631041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical