Provider Demographics
NPI:1891190187
Name:O'CONNELL, JILLIAN ALYSSA
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:ALYSSA
Last Name:O'CONNELL
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 1:276 AUTUMN RDG
Mailing Address - Street 2:
Mailing Address - City:ALTENBURG
Mailing Address - State:MO
Mailing Address - Zip Code:63732-9181
Mailing Address - Country:US
Mailing Address - Phone:573-450-7632
Mailing Address - Fax:
Practice Address - Street 1:276 AUTUMN RDG
Practice Address - Street 2:
Practice Address - City:ALTENBURG
Practice Address - State:MO
Practice Address - Zip Code:63732-9181
Practice Address - Country:US
Practice Address - Phone:573-450-7632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-29
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014016034235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist