Provider Demographics
NPI:1104908706
Name:SALEM, JILL E (PHD, HSPP)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:E
Last Name:SALEM
Suffix:
Gender:F
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 RAVINIA RD
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-2361
Mailing Address - Country:US
Mailing Address - Phone:765-742-1826
Mailing Address - Fax:
Practice Address - Street 1:1415 SALEM ST
Practice Address - Street 2:SUITE 102
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-4100
Practice Address - Country:US
Practice Address - Phone:765-742-1816
Practice Address - Fax:765-742-2557
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041615A103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200283590AMedicaid
IN200283590AMedicaid