Provider Demographics
NPI:1598402059
Name:WILLIS, KIERA BRIEANNE-JACKSON
Entity Type:Individual
Prefix:MRS
First Name:KIERA
Middle Name:BRIEANNE-JACKSON
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KIERA
Other - Middle Name:BRIEANNE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5400 BOBCAT ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:CO
Mailing Address - Zip Code:80504-5474
Mailing Address - Country:US
Mailing Address - Phone:303-956-1263
Mailing Address - Fax:
Practice Address - Street 1:4155 E JEWELL AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-4504
Practice Address - Country:US
Practice Address - Phone:720-456-8054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSLP.0000935235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist