Provider Demographics
NPI:1659332690
Name:JOHANNSEN, JILL KRISTA (DPT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:KRISTA
Last Name:JOHANNSEN
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 1:810 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-2135
Mailing Address - Country:US
Mailing Address - Phone:053-315-8906
Mailing Address - Fax:605-336-3974
Practice Address - Street 1:810 E 23RD ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105
Practice Address - Country:US
Practice Address - Phone:605-331-5890
Practice Address - Fax:605-336-3974
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1122208100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE46030609213Medicaid
SD6402180Medicaid
MN393065300Medicaid
NE46030609213Medicaid