Provider Demographics
NPI:1154596419
Name:LAWRENCE, JILL NICOLE (CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:NICOLE
Last Name:LAWRENCE
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:PO BOX 53
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:GA
Mailing Address - Zip Code:30411-0053
Mailing Address - Country:US
Mailing Address - Phone:912-523-5683
Mailing Address - Fax:
Practice Address - Street 1:1400 NE MAIN ST
Practice Address - Street 2:BETHANY ALF
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474
Practice Address - Country:US
Practice Address - Phone:912-375-3797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4920235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist