Provider Demographics
NPI:1265881486
Name:ROBERTS, JILL (PSYD)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 613
Mailing Address - Street 2:
Mailing Address - City:CHANNAHON
Mailing Address - State:IL
Mailing Address - Zip Code:60410-0613
Mailing Address - Country:US
Mailing Address - Phone:815-521-1889
Mailing Address - Fax:815-521-1889
Practice Address - Street 1:11227 DISTINCTIVE DR
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-9458
Practice Address - Country:US
Practice Address - Phone:815-321-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009296103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist