Provider Demographics
NPI:1477980381
Name:PETERSEN, JILL M (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:JILL
Middle Name:M
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 BRISBANE WOODS WAY
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-9255
Mailing Address - Country:US
Mailing Address - Phone:919-455-8466
Mailing Address - Fax:
Practice Address - Street 1:2024 BRISBANE WOODS WAY
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-9255
Practice Address - Country:US
Practice Address - Phone:919-455-8466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-09
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10057235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist