Provider Demographics
NPI:1932433216
Name:SHULTS, JILL (MMSC-CCC/SPEECH PATH)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:SHULTS
Suffix:
Gender:F
Credentials:MMSC-CCC/SPEECH PATH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5910 PLANTATION DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-2866
Mailing Address - Country:US
Mailing Address - Phone:678-234-9779
Mailing Address - Fax:
Practice Address - Street 1:5910 PLANTATION DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-2866
Practice Address - Country:US
Practice Address - Phone:678-234-9779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-20
Last Update Date:2009-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP000711235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist