Provider Demographics
NPI:1992119283
Name:JILL VAN PELT LCSW PLLC
Entity type:Organization
Organization Name:JILL VAN PELT LCSW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MESKUNAS-VAN PELT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-595-9120
Mailing Address - Street 1:29 DOWNS AVE
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-1822
Mailing Address - Country:US
Mailing Address - Phone:607-595-9120
Mailing Address - Fax:
Practice Address - Street 1:4513 OLD VESTAL RD
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-3571
Practice Address - Country:US
Practice Address - Phone:607-729-7001
Practice Address - Fax:607-729-6434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0699781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03115804Medicaid
NY03115804Medicaid
RA2363Medicare PIN