Provider Demographics
NPI:1063892511
Name:LINDHOLM, JILL (LADC)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:LINDHOLM
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 4TH ST NW STE 300
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-3196
Mailing Address - Country:US
Mailing Address - Phone:218-751-3280
Mailing Address - Fax:218-751-3298
Practice Address - Street 1:403 4TH ST NW STE 300
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3196
Practice Address - Country:US
Practice Address - Phone:218-444-5155
Practice Address - Fax:218-333-3921
Is Sole Proprietor?:No
Enumeration Date:2015-05-30
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302430101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1063892511Medicaid