Healthcare Provider Details

I. General information

NPI: 1285879023
Provider Name (Legal Business Name): JILL BUMGARNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILL MULLEN

II. Dates (important events)

Enumeration Date: 12/09/2008
Last Update Date: 04/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MULBARRY ST
ELIZABETH WV
26143-0189
US

IV. Provider business mailing address

1 MULBARRY ST
ELIZABETH WV
26143-0189
US

V. Phone/Fax

Practice location:
  • Phone: 304-275-4279
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP-1142
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: