Provider Demographics
NPI:1487896155
Name:TATE, JILL NICOLE DEYMONAZ (SLP)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:NICOLE DEYMONAZ
Last Name:TATE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 NE 80TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-4211
Mailing Address - Country:US
Mailing Address - Phone:503-282-2412
Mailing Address - Fax:
Practice Address - Street 1:4201 NE 80TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97218-4211
Practice Address - Country:US
Practice Address - Phone:503-351-8599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-27
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12604235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist