Provider Demographics
NPI:1134638349
Name:JOHNSON, JILL ANNE
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ANNE
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 1:98 WARNER HILL RD
Mailing Address - Street 2:
Mailing Address - City:TICONDEROGA
Mailing Address - State:NY
Mailing Address - Zip Code:12883-3701
Mailing Address - Country:US
Mailing Address - Phone:518-586-1457
Mailing Address - Fax:
Practice Address - Street 1:128 PARK ROW STE 101
Practice Address - Street 2:
Practice Address - City:CADYVILLE
Practice Address - State:NY
Practice Address - Zip Code:12918-2817
Practice Address - Country:US
Practice Address - Phone:518-561-6361
Practice Address - Fax:518-293-5226
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist