Provider Demographics
NPI:1619854650
Name:HUMPHREY, JILLIAN RAE (LMSW)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:RAE
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9694 ROANOKE RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14143-9536
Mailing Address - Country:US
Mailing Address - Phone:716-983-8160
Mailing Address - Fax:
Practice Address - Street 1:7014 BIG TREE RD
Practice Address - Street 2:
Practice Address - City:PAVILION
Practice Address - State:NY
Practice Address - Zip Code:14525-9138
Practice Address - Country:US
Practice Address - Phone:585-584-3115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-20
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1284791041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool