=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184352643
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JILL BANGS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2022
-----------------------------------------------------
Last Update Date | 08/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16260 PARK LAKE RD
-----------------------------------------------------
City | EAST LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48823-9480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-339-2322
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12725 MAHOGANY WAY
-----------------------------------------------------
City | DEWITT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48820-7860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 7101002283
-----------------------------------------------------
License Number State |
-----------------------------------------------------