Provider Demographics
NPI:1780189159
Name:MAHONEY, JILL CORBIN (PT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:CORBIN
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:SUZANNE
Other - Last Name:CORBIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:821 SCARLET OAK DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-3481
Mailing Address - Country:US
Mailing Address - Phone:419-349-8311
Mailing Address - Fax:
Practice Address - Street 1:718 N MACOMB ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-7815
Practice Address - Country:US
Practice Address - Phone:734-240-1950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005325225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist