Provider Demographics
NPI:1811259526
Name:DAVIS, JILL LYNN (CCC/SLP)
Entity type:Individual
Prefix:MS
First Name:JILL
Middle Name:LYNN
Last Name:DAVIS
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 1:21205 BRAXFIELD LOOP
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-3242
Mailing Address - Country:US
Mailing Address - Phone:239-404-4717
Mailing Address - Fax:
Practice Address - Street 1:6150 DIAMOND CENTRE CT
Practice Address - Street 2:SUITE 203
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4368
Practice Address - Country:US
Practice Address - Phone:239-482-3154
Practice Address - Fax:239-482-3254
Is Sole Proprietor?:No
Enumeration Date:2012-06-10
Last Update Date:2012-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5697235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist