Provider Demographics
NPI:1053742478
Name:VANSELOW, JILLIAN
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:VANSELOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34225 N 27TH DR
Mailing Address - Street 2:BLDG 5 SUITE 138
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-6087
Mailing Address - Country:US
Mailing Address - Phone:602-810-1130
Mailing Address - Fax:
Practice Address - Street 1:34225 N 27TH DR
Practice Address - Street 2:BLDG 5 SUITE 138
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-6087
Practice Address - Country:US
Practice Address - Phone:602-810-1130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13339101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)