Provider Demographics
NPI:1093055733
Name:JOHNSON, JILL MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2224 HAZELHURST CT
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45440-1137
Mailing Address - Country:US
Mailing Address - Phone:937-367-9077
Mailing Address - Fax:
Practice Address - Street 1:2224 HAZELHURST CT
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45440-1137
Practice Address - Country:US
Practice Address - Phone:937-367-9077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-17
Last Update Date:2013-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH148396-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse