Provider Demographics
NPI:1508121948
Name:JOHNSON, JILL MARIE (DO)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 CLEMSON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7925
Mailing Address - Country:US
Mailing Address - Phone:803-438-3800
Mailing Address - Fax:803-438-3898
Practice Address - Street 1:460 CLEMSON RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-7925
Practice Address - Country:US
Practice Address - Phone:803-438-3800
Practice Address - Fax:803-438-3898
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS14223207V00000X
SCLL1572207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology