Provider Demographics
NPI:1215022538
Name:TIEMAN, JILL R (DC)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:R
Last Name:TIEMAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:671 MONTAUK HWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:BAYPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11705-1607
Mailing Address - Country:US
Mailing Address - Phone:631-472-1095
Mailing Address - Fax:631-472-8221
Practice Address - Street 1:671 MONTAUK HWY
Practice Address - Street 2:SUITE A
Practice Address - City:BAYPORT
Practice Address - State:NY
Practice Address - Zip Code:11705-1607
Practice Address - Country:US
Practice Address - Phone:631-472-1095
Practice Address - Fax:631-472-8221
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYXOO 6115-1111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX40221Medicare ID - Type Unspecified