Provider Demographics
NPI:1619533866
Name:PEDERSEN, JILL (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8289 OLD POST RD E
Mailing Address - Street 2:
Mailing Address - City:EAST AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14051-1584
Mailing Address - Country:US
Mailing Address - Phone:626-260-5450
Mailing Address - Fax:
Practice Address - Street 1:6395 OLD NIAGARA RD
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-1421
Practice Address - Country:US
Practice Address - Phone:626-260-5450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028729235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist