Provider Demographics
NPI:1003457102
Name:KELLNER, JILL ELIZABETH (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ELIZABETH
Last Name:KELLNER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4102 BELMONT PT
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-3506
Mailing Address - Country:US
Mailing Address - Phone:217-621-3458
Mailing Address - Fax:
Practice Address - Street 1:404 S 5TH ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:IL
Practice Address - Zip Code:61873-9073
Practice Address - Country:US
Practice Address - Phone:217-469-2291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146008666235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist