Provider Demographics
NPI:1407215155
Name:GOODMAN, JILLIAN (SLP-CCC)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 W LAS OLAS BLVD APT 2404
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-3091
Mailing Address - Country:US
Mailing Address - Phone:954-599-4650
Mailing Address - Fax:
Practice Address - Street 1:4 W LAS OLAS BLVD APT 2404
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-3091
Practice Address - Country:US
Practice Address - Phone:954-599-4650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-22
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA18217235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist