Provider Demographics
NPI:1407526866
Name:JOHNSON, JAYME RENEE (PTA)
Entity Type:Individual
Prefix:
First Name:JAYME
Middle Name:RENEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 N UNION ST
Mailing Address - Street 2:
Mailing Address - City:GOOD HOPE
Mailing Address - State:IL
Mailing Address - Zip Code:61438-9172
Mailing Address - Country:US
Mailing Address - Phone:309-337-4231
Mailing Address - Fax:
Practice Address - Street 1:145 S CHAMBERLAIN ST
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:IL
Practice Address - Zip Code:61473-9581
Practice Address - Country:US
Practice Address - Phone:309-426-2134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160008612225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant