Provider Demographics
NPI:1891818605
Name:RIZK, JILL RICHERT (CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:JILL
Middle Name:RICHERT
Last Name:RIZK
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 1:148 RANCH RD
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70460-3325
Mailing Address - Country:US
Mailing Address - Phone:985-649-9784
Mailing Address - Fax:
Practice Address - Street 1:148 RANCH RD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70460-3325
Practice Address - Country:US
Practice Address - Phone:985-649-9784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3216235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1068951Medicaid