Healthcare Provider Details

I. General information

NPI: 1528310109
Provider Name (Legal Business Name): JILL A WICKHAM SLP-CCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2012
Last Update Date: 10/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1999 OLD MOULTRIE RD
ST AUGUSTINE FL
32086-5164
US

IV. Provider business mailing address

PO BOX 734
DEFUNIAK SPGS FL
32435-0734
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-3311
  • Fax:
Mailing address:
  • Phone: 850-225-0538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA8304
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: