Provider Demographics
NPI:1952419798
Name:SKIDMORE-ERICKSON, JILL (PT)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:
Last Name:SKIDMORE-ERICKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1127
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-1127
Mailing Address - Country:US
Mailing Address - Phone:907-262-2980
Mailing Address - Fax:
Practice Address - Street 1:36275 KENAI SPUR HWY., STE 5
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669
Practice Address - Country:US
Practice Address - Phone:907-260-2679
Practice Address - Fax:907-260-2676
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK229225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKK151941Medicare ID - Type UnspecifiedRENDERING PROVIDER ID