Provider Demographics
NPI:1821566803
Name:JOHNSON, JILL A (LMT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 W PATRICK ST STE 2
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-6910
Mailing Address - Country:US
Mailing Address - Phone:301-693-7639
Mailing Address - Fax:
Practice Address - Street 1:263 W PATRICK ST STE 2
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-6910
Practice Address - Country:US
Practice Address - Phone:301-693-7639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM05090225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist