Provider Demographics
NPI:1740645233
Name:NORMAN, JILLIAN (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:NORMAN
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 1:11214 E DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33584-8359
Mailing Address - Country:US
Mailing Address - Phone:813-461-3111
Mailing Address - Fax:813-643-9051
Practice Address - Street 1:11214 E DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:SEFFNER
Practice Address - State:FL
Practice Address - Zip Code:33584-8359
Practice Address - Country:US
Practice Address - Phone:813-461-3111
Practice Address - Fax:813-643-9051
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-28
Last Update Date:2024-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13967235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1740645233Medicaid
FL123145800Medicaid