Provider Demographics
NPI:1316087489
Name:DAVIS, JILL
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:
Last Name:DAVIS
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:PO BOX 1187
Mailing Address - Street 2:
Mailing Address - City:CORTARO
Mailing Address - State:AZ
Mailing Address - Zip Code:85652-1187
Mailing Address - Country:US
Mailing Address - Phone:520-616-7406
Mailing Address - Fax:
Practice Address - Street 1:11279 W GRIER RD
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85653-9609
Practice Address - Country:US
Practice Address - Phone:520-682-4782
Practice Address - Fax:520-682-4818
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP4958235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist