Provider Demographics
NPI:1437814464
Name:BALLANTYNE, JILL
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:BALLANTYNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:LEADERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6270 EVAN CIR
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-4398
Mailing Address - Country:US
Mailing Address - Phone:608-387-5693
Mailing Address - Fax:
Practice Address - Street 1:6270 EVAN CIR
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-4398
Practice Address - Country:US
Practice Address - Phone:608-387-5693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-04
Last Update Date:2022-08-22
Deactivation Date:2022-07-01
Deactivation Code:
Reactivation Date:2022-08-21
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist