Provider Demographics
NPI:1316142540
Name:WOODARD, JILL LAURIE (ST)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:LAURIE
Last Name:WOODARD
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:LAUIRE
Other - Last Name:OWENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2725 WATER RIDGE PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-4580
Mailing Address - Country:US
Mailing Address - Phone:704-831-5065
Mailing Address - Fax:705-831-5066
Practice Address - Street 1:126 MILLPORT CIR
Practice Address - Street 2:SUITE 201
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5562
Practice Address - Country:US
Practice Address - Phone:864-329-1480
Practice Address - Fax:864-329-8427
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3967235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3967OtherSPEECH LANGUAGE
SC8560Medicare PIN