Provider Demographics
NPI:1023396538
Name:JOHNSON, JILL
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:JOHNSON
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 1:5530 S 1100 E-57
Mailing Address - Street 2:
Mailing Address - City:HUNTERTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46748-9504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5530 S 1100 E-57
Practice Address - Street 2:
Practice Address - City:HUNTERTOWN
Practice Address - State:IN
Practice Address - Zip Code:46748-9504
Practice Address - Country:US
Practice Address - Phone:260-403-7160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.364145163W00000X
IN28167518A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse