Provider Demographics
NPI:1972218345
Name:VAN LEESTEN, JILL (LCSW)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:VAN LEESTEN
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 YORK AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-5835
Mailing Address - Country:US
Mailing Address - Phone:404-964-3202
Mailing Address - Fax:
Practice Address - Street 1:460 PINE ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-1358
Practice Address - Country:US
Practice Address - Phone:401-274-9373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-19
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICSW028351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty