Provider Demographics
NPI:1811323488
Name:SIMMONS GILLIGAN, JORDAN KENDRICK (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:JORDAN
Middle Name:KENDRICK
Last Name:SIMMONS GILLIGAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MS
Other - First Name:JORDAN
Other - Middle Name:KENDRICK
Other - Last Name:SIMMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:6505 SHILOH RD STE 320
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-1647
Mailing Address - Country:US
Mailing Address - Phone:678-648-7644
Mailing Address - Fax:
Practice Address - Street 1:6505 SHILOH RD STE 320
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-1647
Practice Address - Country:US
Practice Address - Phone:678-648-7644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007962235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00609056GMedicaid