Provider Demographics
NPI:1104882679
Name:FISCHBERG, JILL LESLIE (LMHC)
Entity type:Individual
Prefix:MS
First Name:JILL
Middle Name:LESLIE
Last Name:FISCHBERG
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6170 53RD AVE E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-9721
Mailing Address - Country:US
Mailing Address - Phone:941-468-4567
Mailing Address - Fax:941-621-6226
Practice Address - Street 1:6170 53RD AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-9721
Practice Address - Country:US
Practice Address - Phone:941-468-4567
Practice Address - Fax:941-621-6226
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 10788101YM0800X, 101YA0400X, 101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003784400Medicaid