Provider Demographics
NPI:1285464826
Name:TISDALE, JILLIAN RENEE
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:RENEE
Last Name:TISDALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2464 E LA COSTA PL
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-4190
Mailing Address - Country:US
Mailing Address - Phone:480-486-6787
Mailing Address - Fax:
Practice Address - Street 1:1313 E OSBORN RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-5678
Practice Address - Country:US
Practice Address - Phone:480-787-5387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA145482355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant