Provider Demographics
NPI:1457516171
Name:GIDCUMB, JILLIAN RENEE (PT, DPT)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:RENEE
Last Name:GIDCUMB
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 RIDGE RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1755
Mailing Address - Country:US
Mailing Address - Phone:219-836-2800
Mailing Address - Fax:219-836-2897
Practice Address - Street 1:1505 US HIGHWAY 41
Practice Address - Street 2:SUITE A20
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375-1321
Practice Address - Country:US
Practice Address - Phone:219-322-5560
Practice Address - Fax:219-322-1549
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-016483225100000X
IN05010452A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist