Provider Demographics
NPI:1780912048
Name:FAZEKAS, JILL A (MS, CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:A
Last Name:FAZEKAS
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 1:158 STATE ST
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-3202
Mailing Address - Country:US
Mailing Address - Phone:203-237-7835
Mailing Address - Fax:
Practice Address - Street 1:158 STATE ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-3202
Practice Address - Country:US
Practice Address - Phone:203-237-7835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-25
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003354235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist