Provider Demographics
NPI:1740248921
Name:KINGSLIEN, JILL MICHELE (MPT)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MICHELE
Last Name:KINGSLIEN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:MICHELE
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12952 BANDERA RD STE 107
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-4733
Mailing Address - Country:US
Mailing Address - Phone:830-393-8800
Mailing Address - Fax:830-393-8828
Practice Address - Street 1:2004 10TH ST
Practice Address - Street 2:
Practice Address - City:FLORESVILLE
Practice Address - State:TX
Practice Address - Zip Code:78114-2770
Practice Address - Country:US
Practice Address - Phone:830-393-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1316957225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8334435Medicaid
WAAB35241Medicare ID - Type Unspecified
WA8334435Medicaid
WAAB35240Medicare ID - Type Unspecified