Provider Demographics
NPI:1255605077
Name:FRIED, JILLIAN ASHLEY (SLP)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:ASHLEY
Last Name:FRIED
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:
Other - Last Name:FRIED
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SLP
Mailing Address - Street 1:139 CORNELL ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-3633
Mailing Address - Country:US
Mailing Address - Phone:845-338-1234
Mailing Address - Fax:845-338-6284
Practice Address - Street 1:139 CORNELL ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-3633
Practice Address - Country:US
Practice Address - Phone:845-338-1234
Practice Address - Fax:845-338-6284
Is Sole Proprietor?:No
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021740235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist