Provider Demographics
NPI:1053687335
Name:SHERRODD WING, JILLIAN E (SLP)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:E
Last Name:SHERRODD WING
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 2077
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2077
Mailing Address - Country:US
Mailing Address - Phone:503-413-5092
Mailing Address - Fax:503-413-1860
Practice Address - Street 1:2121 NE 139TH ST
Practice Address - Street 2:MOB A, STE 200
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2316
Practice Address - Country:US
Practice Address - Phone:360-487-1777
Practice Address - Fax:360-487-1779
Is Sole Proprietor?:No
Enumeration Date:2012-03-30
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPENDINGMedicaid