Provider Demographics
NPI:1336649094
Name:SPONSELLER, JILL DENISE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:DENISE
Last Name:SPONSELLER
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 THREE LEAVES DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-5523
Mailing Address - Country:US
Mailing Address - Phone:989-779-5604
Mailing Address - Fax:989-779-1839
Practice Address - Street 1:2600 THREE LEAVES DR
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-5523
Practice Address - Country:US
Practice Address - Phone:989-779-5604
Practice Address - Fax:989-779-1839
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101000208235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist