Provider Demographics
NPI:1386702561
Name:BOIKE, JILL DIANE (LICSW)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:DIANE
Last Name:BOIKE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11800 ABERDEEN ST NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4810
Mailing Address - Country:US
Mailing Address - Phone:763-270-0054
Mailing Address - Fax:763-208-6371
Practice Address - Street 1:11800 ABERDEEN ST NE
Practice Address - Street 2:SUITE 100
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-4810
Practice Address - Country:US
Practice Address - Phone:763-270-0054
Practice Address - Fax:763-208-6371
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN152071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN637982000Medicaid