Provider Demographics
NPI:1609398106
Name:BUMGARDNER, JILL (LCSW)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:BUMGARDNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:1704-874-1904
Mailing Address - Fax:704-874-0707
Practice Address - Street 1:609 N HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-2179
Practice Address - Country:US
Practice Address - Phone:704-874-9005
Practice Address - Fax:704-874-9005
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0125841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical