Provider Demographics
NPI:1104605773
Name:DAGISTINO, JILL ANN
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:ANN
Last Name:DAGISTINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3070 EQUESTRIAN DR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-3356
Mailing Address - Country:US
Mailing Address - Phone:954-816-5553
Mailing Address - Fax:
Practice Address - Street 1:2350 W YAMATO RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-8401
Practice Address - Country:US
Practice Address - Phone:561-241-9014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH21616101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health