Provider Demographics
NPI:1194130096
Name:WALTERS, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:WALTERS
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 1:349 SCOLA RD
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:19015-1417
Mailing Address - Country:US
Mailing Address - Phone:484-480-8900
Mailing Address - Fax:
Practice Address - Street 1:500 W 10TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-1422
Practice Address - Country:US
Practice Address - Phone:302-230-9157
Practice Address - Fax:302-984-3324
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACD-0000035101YM0800X
DE750101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)