Provider Demographics
NPI:1396048062
Name:ROBERTSON, JILL MARIE (LAC)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 LAKE ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1085
Mailing Address - Country:US
Mailing Address - Phone:708-386-5630
Mailing Address - Fax:708-386-5645
Practice Address - Street 1:1101 LAKE ST
Practice Address - Street 2:SUITE 300
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1085
Practice Address - Country:US
Practice Address - Phone:708-386-5630
Practice Address - Fax:708-386-5645
Is Sole Proprietor?:No
Enumeration Date:2010-12-17
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.000931171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist