1548336837 NPI number — MRS. JILL SUSAN PEREZ MS CCC SLP

Table of content: MRS. JILL SUSAN PEREZ MS CCC SLP (NPI 1548336837)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548336837 NPI number — MRS. JILL SUSAN PEREZ MS CCC SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEREZ
Provider First Name:
JILL
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS CCC SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RANDALL
Provider Other First Name:
JILL
Provider Other Middle Name:
SUSAN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS CCC SLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1548336837
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
36397 N GANTZEL RD
Provider Second Line Business Mailing Address:
102
Provider Business Mailing Address City Name:
SAN TAN VALLEY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85140-7335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-567-2987
Provider Business Mailing Address Fax Number:
480-347-0240

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36397 N GANTZEL RD
Provider Second Line Business Practice Location Address:
102
Provider Business Practice Location Address City Name:
SAN TAN VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85140-7335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-567-2987
Provider Business Practice Location Address Fax Number:
480-347-0240
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP4178 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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