Provider Demographics
NPI:1124353891
Name:DOUGLASS, JILL (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:DOUGLASS
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 1:315 S COLLEGE RD
Mailing Address - Street 2:SUITE 195
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-3212
Mailing Address - Country:US
Mailing Address - Phone:337-504-4244
Mailing Address - Fax:337-706-7612
Practice Address - Street 1:315 S COLLEGE RD
Practice Address - Street 2:SUITE 195
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-3212
Practice Address - Country:US
Practice Address - Phone:337-504-4244
Practice Address - Fax:337-706-7612
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5787235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist