Provider Demographics
NPI:1831669373
Name:REYNOLDS, JILL DENISE
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:DENISE
Last Name:REYNOLDS
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 1:144 CONTINENTE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-7102
Mailing Address - Country:US
Mailing Address - Phone:925-513-2440
Mailing Address - Fax:
Practice Address - Street 1:144 CONTINENTE AVE STE 100
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-7102
Practice Address - Country:US
Practice Address - Phone:925-513-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASPA1929235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist