Provider Demographics
NPI:1366456527
Name:PRUVOST, JILL ANNE (MS, CCC-A)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ANNE
Last Name:PRUVOST
Suffix:
Gender:F
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7301 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2017
Mailing Address - Country:US
Mailing Address - Phone:309-589-5900
Mailing Address - Fax:309-683-4120
Practice Address - Street 1:7301 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2017
Practice Address - Country:US
Practice Address - Phone:309-589-5900
Practice Address - Fax:309-683-4120
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147.001201231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist