Provider Demographics
NPI:1376828855
Name:MARR, JILLIAN RENEE
Entity Type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:RENEE
Last Name:MARR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-3476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-3476
Practice Address - Country:US
Practice Address - Phone:516-887-8065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012862235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist