Provider Demographics
NPI:1093065443
Name:RIVERS, JILLIAN BETH (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:BETH
Last Name:RIVERS
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 1:1301 ARTISAN AVE E # B
Mailing Address - Street 2:
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747-4064
Mailing Address - Country:US
Mailing Address - Phone:401-636-2216
Mailing Address - Fax:
Practice Address - Street 1:1301 ARTISAN AVE E # B
Practice Address - Street 2:
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-4064
Practice Address - Country:US
Practice Address - Phone:401-636-2216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RISP00260-P235Z00000X
FLSA14710235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RISP00260-POtherPROFESSIONAL LICENSE
FLSA14710OtherFLORIDA DOH