Provider Demographics
NPI:1528284189
Name:WHITE, JILL A (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:A
Last Name:WHITE
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2602 DIAMOND SPUR ST
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-7290
Mailing Address - Country:US
Mailing Address - Phone:928-692-9246
Mailing Address - Fax:928-753-3637
Practice Address - Street 1:2602 DIAMOND SPUR ST
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-7290
Practice Address - Country:US
Practice Address - Phone:928-692-9246
Practice Address - Fax:928-753-3637
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0470235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0470OtherHEALTH DEPT. LIC.