Provider Demographics
NPI:1720291461
Name:DETTMER, JILL RENEE
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:RENEE
Last Name:DETTMER
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 1:0270W 1100N
Mailing Address - Street 2:
Mailing Address - City:OSSIAN
Mailing Address - State:IN
Mailing Address - Zip Code:46777
Mailing Address - Country:US
Mailing Address - Phone:260-638-4664
Mailing Address - Fax:
Practice Address - Street 1:215 DAVIS RD
Practice Address - Street 2:
Practice Address - City:OSSIAN
Practice Address - State:IN
Practice Address - Zip Code:46777-9352
Practice Address - Country:US
Practice Address - Phone:260-622-7821
Practice Address - Fax:260-622-4370
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22003241A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist