Provider Demographics
NPI:1083884415
Name:BLANKENBERG, JILL GWALTNEY (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:GWALTNEY
Last Name:BLANKENBERG
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5350 VINNING ST
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-2936
Mailing Address - Country:US
Mailing Address - Phone:704-783-2580
Mailing Address - Fax:
Practice Address - Street 1:5350 VINNING ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-2936
Practice Address - Country:US
Practice Address - Phone:704-783-2580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-29
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5410235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist