Provider Demographics
NPI:1528649480
Name:NOWAKOWSKI, JILLIAN (SLP)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:NOWAKOWSKI
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:
Other - Last Name:VANDERVELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6895 MORRO RD
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-4122
Mailing Address - Country:US
Mailing Address - Phone:805-464-2133
Mailing Address - Fax:
Practice Address - Street 1:6895 MORRO RD
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-4122
Practice Address - Country:US
Practice Address - Phone:805-464-2133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15450235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty