Basic Information
| Provider Information | |||||||||
| NPI: | 1124084744 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROWNOVER | ||||||||
| FirstName: | JILL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 847556 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752847556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547242111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2401 S 31ST ST | ||||||||
| Address2: | |||||||||
| City: | TEMPLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765080001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547242111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2006 | ||||||||
| LastUpdateDate: | 07/11/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 102229 | TX | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 87555T | 01 | TX | BLUE SHIELD | OTHER |