Provider Demographics
NPI:1346978897
Name:JOHNSON, JILLIAN BLAIR
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:BLAIR
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 1:420 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:EUNICE
Mailing Address - State:LA
Mailing Address - Zip Code:70535-5302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12020 PACIFIC ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-3507
Practice Address - Country:US
Practice Address - Phone:800-259-9897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACP014588A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant