Provider Demographics
NPI:1811607559
Name:PENDERGAST, JILLIAN LEE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:LEE
Last Name:PENDERGAST
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11520 ECHO LAKE CIR UNIT 308
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34211-2510
Mailing Address - Country:US
Mailing Address - Phone:401-703-0195
Mailing Address - Fax:
Practice Address - Street 1:11520 ECHO LAKE CIR UNIT 308
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34211-2510
Practice Address - Country:US
Practice Address - Phone:401-703-0195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19587235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist