Provider Demographics
NPI:1407936172
Name:LONGFELLOW, JILL MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:LONGFELLOW
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5936 N KEYSTONE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-2458
Mailing Address - Country:US
Mailing Address - Phone:317-257-8340
Mailing Address - Fax:317-257-8361
Practice Address - Street 1:5936 N KEYSTONE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-2458
Practice Address - Country:US
Practice Address - Phone:317-257-8340
Practice Address - Fax:317-257-8361
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009105A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000487333OtherTHERAPIST ANTHEM PROV
000000487333OtherTHERAPIST ANTHEM PROV