Provider Demographics
NPI:1073003133
Name:STAFFENBERG, JILL (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:STAFFENBERG
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:GROSSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:10993 OPACA LN
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5616
Mailing Address - Country:US
Mailing Address - Phone:727-460-2502
Mailing Address - Fax:
Practice Address - Street 1:3820 NINE MILE RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-4831
Practice Address - Country:US
Practice Address - Phone:727-460-2502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202008842235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist