Basic Information
Provider Information
NPI: 1033557186
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TILLMAN-JONES
FirstName: DAPHNE
MiddleName: ANN
NamePrefix: MS.
NameSuffix:  
Credential: SLP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2927 BLUE JAY TRL
Address2:  
City: WAYCROSS
State: GA
PostalCode: 315017678
CountryCode: US
TelephoneNumber: 9122883574
FaxNumber:  
Practice Location
Address1: 2927 BLUE JAY TRL
Address2:  
City: WAYCROSS
State: GA
PostalCode: 315017678
CountryCode: US
TelephoneNumber: 9122883574
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/11/2013
LastUpdateDate: 06/11/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
235Z00000XSLP003805GAY Speech, Language and Hearing Service ProvidersSpeech-Language Pathologist 

No ID Information.


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