Provider Demographics
NPI:1609655570
Name:MCDONALD, JILL KEETCH
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:KEETCH
Last Name:MCDONALD
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 1:250 MOHAWK AVE
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2225
Mailing Address - Country:US
Mailing Address - Phone:208-709-9401
Mailing Address - Fax:
Practice Address - Street 1:150 SHOUP AVE STE 19
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3653
Practice Address - Country:US
Practice Address - Phone:208-705-5443
Practice Address - Fax:208-528-4076
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTSLP-5803235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist