Provider Demographics
NPI:1053866178
Name:LANDGREBE, JILL
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:LANDGREBE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1564 SE ROYAL GREEN CIR APT U202
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-4634
Mailing Address - Country:US
Mailing Address - Phone:772-323-1974
Mailing Address - Fax:
Practice Address - Street 1:2631 SW 4TH ST
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-7537
Practice Address - Country:US
Practice Address - Phone:772-626-7637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA12546235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist