Provider Demographics
NPI:1083167993
Name:WIDEM, JILL
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:WIDEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:KATHERINE
Other - Last Name:AMUNDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS,
Mailing Address - Street 1:775 ELLSBOROUGH CT
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30005-2575
Mailing Address - Country:US
Mailing Address - Phone:404-518-0944
Mailing Address - Fax:
Practice Address - Street 1:775 ELLSBOROUGH CT
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30005-2575
Practice Address - Country:US
Practice Address - Phone:404-518-0944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007721235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist