Provider Demographics
NPI:1033284278
Name:JOHNSON, JILL MARIE (RD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:MARIE
Other - Last Name:GENGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC- 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-267-7400
Mailing Address - Fax:616-267-7444
Practice Address - Street 1:8333 FELCH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-2608
Practice Address - Country:US
Practice Address - Phone:616-994-6677
Practice Address - Fax:616-494-5901
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N67770Medicare PIN
MI0M74460Medicare PIN