Healthcare Provider Details

I. General information

NPI: 1407526866
Provider Name (Legal Business Name): JAYME RENEE JOHNSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 09/20/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 S CHAMBERLAIN ST
ROSEVILLE IL
61473-9581
US

IV. Provider business mailing address

225 N UNION ST
GOOD HOPE IL
61438-9172
US

V. Phone/Fax

Practice location:
  • Phone: 309-426-2134
  • Fax:
Mailing address:
  • Phone: 309-337-4231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160008612
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: