Provider Demographics
NPI:1689787624
Name:LANE, JILL SUZANNE (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:SUZANNE
Last Name:LANE
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MRS
Other - First Name:JILL
Other - Middle Name:SUZANNE
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:995 SW 147 AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027
Mailing Address - Country:US
Mailing Address - Phone:954-290-4277
Mailing Address - Fax:954-584-7816
Practice Address - Street 1:5451 DAVIE ROAD
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314
Practice Address - Country:US
Practice Address - Phone:954-290-4277
Practice Address - Fax:954-584-7816
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7798235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12024125OtherASHA
FL888544300Medicaid