Provider Demographics
NPI:1891393104
Name:MARTIN, JILL C (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:C
Last Name:MARTIN
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 1:601 CRAWFORD ST
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-4315
Mailing Address - Country:US
Mailing Address - Phone:503-750-0555
Mailing Address - Fax:
Practice Address - Street 1:601 CRAWFORD ST
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-4315
Practice Address - Country:US
Practice Address - Phone:503-750-5055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL61103904235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist