Provider Demographics
NPI:1588131726
Name:KINNEY, JILLIAN THERESA (MS)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:THERESA
Last Name:KINNEY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4024 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33711-1239
Mailing Address - Country:US
Mailing Address - Phone:727-535-9811
Mailing Address - Fax:903-793-1203
Practice Address - Street 1:2188 58TH ST N
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-3112
Practice Address - Country:US
Practice Address - Phone:903-794-2705
Practice Address - Fax:903-793-1203
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-18-56214106S00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician