Provider Demographics
NPI:1154821841
Name:WALCOTT, JILLIAN BETH (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:BETH
Last Name:WALCOTT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 CECELIA ST
Mailing Address - Street 2:
Mailing Address - City:COMBINED LOCKS
Mailing Address - State:WI
Mailing Address - Zip Code:54113-1408
Mailing Address - Country:US
Mailing Address - Phone:616-401-6511
Mailing Address - Fax:
Practice Address - Street 1:2725 S MOORLAND RD STE 301
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-3720
Practice Address - Country:US
Practice Address - Phone:414-329-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6464-154235Z00000X
OK4917235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist