Provider Demographics
NPI:1467768523
Name:SHERIDAN, JILL RENEE (SLP CCC S)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:RENEE
Last Name:SHERIDAN
Suffix:
Gender:F
Credentials:SLP CCC S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 PREAKNESS CT
Mailing Address - Street 2:
Mailing Address - City:RACELAND
Mailing Address - State:KY
Mailing Address - Zip Code:41169-1093
Mailing Address - Country:US
Mailing Address - Phone:606-388-4268
Mailing Address - Fax:
Practice Address - Street 1:3040 PREAKNESS CT
Practice Address - Street 2:
Practice Address - City:RACELAND
Practice Address - State:KY
Practice Address - Zip Code:41169-1093
Practice Address - Country:US
Practice Address - Phone:606-388-4268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2096235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist