Provider Demographics
NPI:1417520198
Name:EDGERLY, JILLIAN NICOLE (CF-SLP)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:NICOLE
Last Name:EDGERLY
Suffix:
Gender:F
Credentials:CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 W 26TH ST APT 4044
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77008-2947
Mailing Address - Country:US
Mailing Address - Phone:409-344-3477
Mailing Address - Fax:
Practice Address - Street 1:67 S HIGLEY RD STE 103-477
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-1166
Practice Address - Country:US
Practice Address - Phone:480-998-1477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118427235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist