Healthcare Provider Details

I. General information

NPI: 1437814464
Provider Name (Legal Business Name): JILL BALLANTYNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JILL LEADERS

II. Dates (important events)

Enumeration Date: 11/04/2021
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date: 07/01/2022
Reactivation Date: 08/21/2022

III. Provider practice location address

6270 EVAN CIR
CRESTVIEW FL
32536-4398
US

IV. Provider business mailing address

6270 EVAN CIR
CRESTVIEW FL
32536-4398
US

V. Phone/Fax

Practice location:
  • Phone: 608-387-5693
  • Fax:
Mailing address:
  • Phone: 608-387-5693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: