Provider Demographics
NPI:1063757268
Name:BLACK, JILL MICHELE (LMFT)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MICHELE
Last Name:BLACK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30101 AGOURA CT
Mailing Address - Street 2:LOBBY 3 SUITE 150
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-5806
Mailing Address - Country:US
Mailing Address - Phone:805-657-2511
Mailing Address - Fax:805-856-2219
Practice Address - Street 1:30101 AGOURA CT
Practice Address - Street 2:LOBBY 3 SUITE 150
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-5806
Practice Address - Country:US
Practice Address - Phone:805-657-2511
Practice Address - Fax:805-856-2219
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-29
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52229106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist