Provider Demographics
NPI:1063884765
Name:VERMEIRE, JILL (MFT)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:VERMEIRE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27143 PEMBINA RD
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-2224
Mailing Address - Country:US
Mailing Address - Phone:310-751-0509
Mailing Address - Fax:
Practice Address - Street 1:916 N WESTERN AVE STE 210
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-2407
Practice Address - Country:US
Practice Address - Phone:310-751-0509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-21
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC41255106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist