Provider Demographics
NPI:1073923082
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 1:6905 BEARGRASS RD
Mailing Address - Street 2:
Mailing Address - City:HARMONY
Mailing Address - State:FL
Mailing Address - Zip Code:34773-9182
Mailing Address - Country:US
Mailing Address - Phone:321-917-7367
Mailing Address - Fax:
Practice Address - Street 1:6905 BEARGRASS RD
Practice Address - Street 2:
Practice Address - City:HARMONY
Practice Address - State:FL
Practice Address - Zip Code:34773-9182
Practice Address - Country:US
Practice Address - Phone:321-917-7367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-29
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT8621314000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility