Provider Demographics
NPI:1306083068
Name:ST AUBIN, JILL R (LMHC)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:R
Last Name:ST AUBIN
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 1:2872 57TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-2570
Mailing Address - Country:US
Mailing Address - Phone:727-709-6962
Mailing Address - Fax:727-344-8786
Practice Address - Street 1:2872 57TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-2570
Practice Address - Country:US
Practice Address - Phone:727-709-6962
Practice Address - Fax:727-344-8786
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-16
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH5811101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL679992296OtherMEDICAID WAIVER
FL679992298OtherMEDICAID WAIVER