Provider Demographics
NPI:1609025659
Name:LAVELLE, JILL M (MED LAC)
Entity type:Individual
Prefix:MS
First Name:JILL
Middle Name:M
Last Name:LAVELLE
Suffix:
Gender:F
Credentials:MED LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102
Mailing Address - Country:US
Mailing Address - Phone:701-261-3113
Mailing Address - Fax:701-298-3496
Practice Address - Street 1:1445 1ST AVE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102
Practice Address - Country:US
Practice Address - Phone:701-261-3113
Practice Address - Fax:701-298-3497
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND1439101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)