Provider Demographics
NPI: | 1366644304 |
---|---|
Name: | KOSHAK-JOHNSON, JILL D (PT) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | JILL |
Middle Name: | D |
Last Name: | KOSHAK-JOHNSON |
Suffix: | |
Gender: | F |
Credentials: | PT |
Other - Prefix: | |
Other - First Name: | JILL |
Other - Middle Name: | D |
Other - Last Name: | KOSHAK |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | PT |
Mailing Address - Street 1: | 1919 GREENTREE ROAD |
Mailing Address - Street 2: | SUITE B |
Mailing Address - City: | CHERRY HILL |
Mailing Address - State: | NJ |
Mailing Address - Zip Code: | 08003 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 856-424-0993 |
Mailing Address - Fax: | 856-424-0994 |
Practice Address - Street 1: | 1919 GREENTREE ROAD |
Practice Address - Street 2: | SUITE B |
Practice Address - City: | CHERRY HILL |
Practice Address - State: | NJ |
Practice Address - Zip Code: | 08003 |
Practice Address - Country: | US |
Practice Address - Phone: | 856-424-0993 |
Practice Address - Fax: | 856-424-0994 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-06-01 |
Last Update Date: | 2016-11-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 070014760 | 225100000X |
NJ | QA01313600 | 2251X0800X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2251X0800X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |