Healthcare Provider Details

I. General information

NPI: 1396029237
Provider Name (Legal Business Name): JILLIAN N. HAZELBAKER CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2011
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 CHILHOWEE MEDICAL PARK
MARYVILLE TN
37804-5285
US

IV. Provider business mailing address

PO BOX 5209
MARYVILLE TN
37802-5209
US

V. Phone/Fax

Practice location:
  • Phone: 865-982-3400
  • Fax: 865-238-2034
Mailing address:
  • Phone: 865-982-3400
  • Fax: 865-238-2034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP-10021
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number4174
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22005131A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5923
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: