Provider Demographics
NPI:1417491473
Name:EVENSEN, JILL (MS, SLP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:EVENSEN
Suffix:
Gender:F
Credentials:MS, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 E 1ST ST # 4237
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3211
Mailing Address - Country:US
Mailing Address - Phone:714-475-3820
Mailing Address - Fax:
Practice Address - Street 1:30 PARMA
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92602-1657
Practice Address - Country:US
Practice Address - Phone:714-475-3820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-10
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10386235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist