Provider Demographics
NPI:1033093836
Name:RUDOLPH, JILLIAN (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 SIMMONS ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02840-3923
Mailing Address - Country:US
Mailing Address - Phone:631-991-1405
Mailing Address - Fax:
Practice Address - Street 1:49 STATE ROAD
Practice Address - Street 2:WATUPPA BUILDING, SUITE 104-105
Practice Address - City:NORTH DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747
Practice Address - Country:US
Practice Address - Phone:508-985-1996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-04
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MASLP101224235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist