Provider Demographics
NPI:1639361991
Name:KING, JILL ELAINE (MCSD)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:ELAINE
Last Name:KING
Suffix:
Gender:F
Credentials:MCSD
Other - Prefix:MRS
Other - First Name:JILL
Other - Middle Name:KING
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MCSD
Mailing Address - Street 1:1719 SALSBURY AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414
Mailing Address - Country:US
Mailing Address - Phone:307-587-5772
Mailing Address - Fax:
Practice Address - Street 1:558 EAST 2ND STREET
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435
Practice Address - Country:US
Practice Address - Phone:307-754-2864
Practice Address - Fax:307-754-9829
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1770688871Medicaid