Provider Demographics
NPI:1588987465
Name:MARTIN, JILL (MA, LLPC, CAAC)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA, LLPC, CAAC
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:COSTELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:31993 W 12 MILE RD
Mailing Address - Street 2:311
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3630
Mailing Address - Country:US
Mailing Address - Phone:248-854-5158
Mailing Address - Fax:
Practice Address - Street 1:31993 W 12 MILE RD
Practice Address - Street 2:311
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3630
Practice Address - Country:US
Practice Address - Phone:248-854-5158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-08
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010625101Y00000X
MIC-00413101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor