Provider Demographics
NPI:1417277989
Name:DERUMS, JILL AMANDA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:AMANDA
Last Name:DERUMS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:AMANDA
Other - Last Name:GIBBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, MS
Mailing Address - Street 1:PO BOX 141
Mailing Address - Street 2:
Mailing Address - City:PINE MOUNTAIN VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31823-0141
Mailing Address - Country:US
Mailing Address - Phone:706-457-9542
Mailing Address - Fax:
Practice Address - Street 1:217 K STREET
Practice Address - Street 2:
Practice Address - City:PINE MOUNTAIN VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31823-0141
Practice Address - Country:US
Practice Address - Phone:706-457-9542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006875225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist