Provider Demographics
NPI:1609527092
Name:SCUDDER, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:SCUDDER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 LEXINGTON PKWY N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4636
Mailing Address - Country:US
Mailing Address - Phone:612-280-2310
Mailing Address - Fax:651-280-3995
Practice Address - Street 1:451 LEXINGTON PKWY N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4636
Practice Address - Country:US
Practice Address - Phone:612-280-2310
Practice Address - Fax:651-280-3995
Is Sole Proprietor?:No
Enumeration Date:2022-01-17
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
MN4868101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst