Provider Demographics
NPI:1144998527
Name:BACA, JILLIAN MARIA (SLPA)
Entity type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:MARIA
Last Name:BACA
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 DESPERADO DR
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-3966
Mailing Address - Country:US
Mailing Address - Phone:719-680-2015
Mailing Address - Fax:
Practice Address - Street 1:2404 DESPERADO DR
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-3966
Practice Address - Country:US
Practice Address - Phone:719-680-2015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO358258235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist