Provider Demographics
NPI:1891149472
Name:PLACE, JILL MARIE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:MARIE
Last Name:PLACE
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 1:425 SOUTH 7TH ST
Mailing Address - Street 2:SOUTHRIDGE CHIROPRACTIC
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58501
Mailing Address - Country:US
Mailing Address - Phone:701-258-8388
Mailing Address - Fax:
Practice Address - Street 1:425 SOUTH 7TH ST
Practice Address - Street 2:SOUTHRIDGE CHIROPRACTIC
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501
Practice Address - Country:US
Practice Address - Phone:701-258-8388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND493225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist