Healthcare Provider Details

I. General information

NPI: 1063766442
Provider Name (Legal Business Name): JILLIAN YUDIN SLPA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2012
Last Update Date: 01/03/2022
Certification Date: 01/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 E ORANGEWOOD AVE
ANAHEIM CA
92805-6807
US

IV. Provider business mailing address

1301 E ORANGEWOOD AVE
ANAHEIM CA
92805-6807
US

V. Phone/Fax

Practice location:
  • Phone: 800-249-1266
  • Fax:
Mailing address:
  • Phone: 800-249-1266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSPA 1402
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number16046
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: