Provider Demographics
NPI:1124670021
Name:BELCHER, JILLIAN ELISE
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:ELISE
Last Name:BELCHER
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 1:4326 LAKE UNDERHILL RD APT D
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-7019
Mailing Address - Country:US
Mailing Address - Phone:703-409-6590
Mailing Address - Fax:
Practice Address - Street 1:100 S KENTUCKY AVE STE 215
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5089
Practice Address - Country:US
Practice Address - Phone:352-708-6283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
VAA62764484106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health