Provider Demographics
NPI:1992952402
Name:JILLIAN FENTON LLC
Entity type:Organization
Organization Name:JILLIAN FENTON LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:JILLIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LICSW
Authorized Official - Phone:401-683-2555
Mailing Address - Street 1:11 KING CHARLES DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORTSMOUTH
Mailing Address - State:RI
Mailing Address - Zip Code:02871-1364
Mailing Address - Country:US
Mailing Address - Phone:401-683-2555
Mailing Address - Fax:
Practice Address - Street 1:11 KING CHARLES DR
Practice Address - Street 2:SUITE A
Practice Address - City:PORTSMOUTH
Practice Address - State:RI
Practice Address - Zip Code:02871-1364
Practice Address - Country:US
Practice Address - Phone:401-683-2555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI016361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI809004958Medicare UPIN