Provider Demographics
NPI:1275770992
Name:JOHNSON, JILL LYNNE (LMT)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:LYNNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 145
Mailing Address - Street 2:
Mailing Address - City:AMBOY
Mailing Address - State:IL
Mailing Address - Zip Code:61310-0145
Mailing Address - Country:US
Mailing Address - Phone:815-857-2458
Mailing Address - Fax:815-857-2749
Practice Address - Street 1:305 JOE DR E
Practice Address - Street 2:
Practice Address - City:AMBOY
Practice Address - State:IL
Practice Address - Zip Code:61310-9492
Practice Address - Country:US
Practice Address - Phone:815-857-2458
Practice Address - Fax:815-857-2749
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-16
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.002367174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist