Provider Demographics
NPI:1063758753
Name:DERMYER, JILL NICOLE (PSYD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:NICOLE
Last Name:DERMYER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4437 CEDAR WOOD DR SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-4214
Mailing Address - Country:US
Mailing Address - Phone:706-207-1450
Mailing Address - Fax:
Practice Address - Street 1:4437 CEDAR WOOD DR SW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-4214
Practice Address - Country:US
Practice Address - Phone:706-207-1450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-27
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GAPSY004554103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program