Provider Demographics
NPI:1114273299
Name:DOHERTY, JILLIAN (MS SLP CCC)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:MS SLP CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19740 GOVERNORS HWY STE 118
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-2085
Mailing Address - Country:US
Mailing Address - Phone:708-799-5569
Mailing Address - Fax:
Practice Address - Street 1:19740 GOVERNORS HWY STE 118
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2085
Practice Address - Country:US
Practice Address - Phone:708-799-5569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-26
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146011217235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist