Provider Demographics
NPI:1871049825
Name:VOGT, JILLIAN MARIE
Entity type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:MARIE
Last Name:VOGT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 WYNDING GATE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-4394
Mailing Address - Country:US
Mailing Address - Phone:314-479-5653
Mailing Address - Fax:
Practice Address - Street 1:421 WYNDING GATE DR
Practice Address - Street 2:
Practice Address - City:LAKE SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-4394
Practice Address - Country:US
Practice Address - Phone:314-479-5653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO12152377235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist