Provider Demographics
NPI:1699536144
Name:STORM, JILL (MED)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:STORM
Suffix:
Gender:
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7251 RICHMOND PL
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63143-2319
Mailing Address - Country:US
Mailing Address - Phone:314-456-9148
Mailing Address - Fax:
Practice Address - Street 1:13303 TESSON FERRY RD STE 50
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-4062
Practice Address - Country:US
Practice Address - Phone:636-379-1779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023028233101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health