Provider Demographics
NPI:1619138864
Name:BOWEN, JILL L (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:L
Last Name:BOWEN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9033 OAKFIELD DR
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30461-7386
Mailing Address - Country:US
Mailing Address - Phone:912-587-7370
Mailing Address - Fax:912-587-7370
Practice Address - Street 1:9033 OAKFIELD DR
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30461-7386
Practice Address - Country:US
Practice Address - Phone:912-587-7370
Practice Address - Fax:912-587-7370
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003750235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000723852BMedicaid