Provider Demographics
NPI:1508550377
Name:MOFFITT, JILLIAN ALYSE
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:ALYSE
Last Name:MOFFITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 WEST CAMPO BELLO DRIVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-6549
Mailing Address - Country:US
Mailing Address - Phone:602-315-0458
Mailing Address - Fax:
Practice Address - Street 1:20329 N 59TH AVE STE A2
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6854
Practice Address - Country:US
Practice Address - Phone:480-613-9961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA144272355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant