Provider Demographics
NPI:1144251190
Name:BOOTH, JILL M (SLP)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:M
Last Name:BOOTH
Suffix:
Gender:F
Credentials:SLP
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 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-3300
Mailing Address - Fax:701-364-8906
Practice Address - Street 1:1702 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4940
Practice Address - Country:US
Practice Address - Phone:701-364-3300
Practice Address - Fax:701-364-8906
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND665235Z00000X
AZSLP8027235Z00000X
ND1311235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND52524Medicaid
ND43G40BOOtherMNBS #
ND20605OtherNDBS #
NDND200229OtherLHS #
AZSLP8027OtherAZ LICENSE
ND4600456OtherMEDICA #
ND1782578OtherAMERICA'S PPO/ARAZ #
ND4600421OtherMEDICA #
ND52524Medicaid
ND715346Medicare PIN