Provider Demographics
NPI:1568400638
Name:PEDERSEN, JILL GREEN (ATC)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:GREEN
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-2002
Mailing Address - Country:US
Mailing Address - Phone:660-747-8466
Mailing Address - Fax:660-429-0500
Practice Address - Street 1:407 E RUSSELL AVE
Practice Address - Street 2:BLDG. A, SUITE 4
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-1242
Practice Address - Country:US
Practice Address - Phone:660-429-4700
Practice Address - Fax:660-429-0500
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20001735622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer