Provider Demographics
NPI:1487989745
Name:ANDERSON, JILL M (MA, LPC)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:673 CHERRY BLOSSOM DR
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-9372
Mailing Address - Country:US
Mailing Address - Phone:704-223-0623
Mailing Address - Fax:
Practice Address - Street 1:215 RONNIE CT STE D-1
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-4204
Practice Address - Country:US
Practice Address - Phone:704-223-0623
Practice Address - Fax:843-432-3091
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8077101YM0800X
SC6063101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC1812Medicaid