Healthcare Provider Details

I. General information

NPI: 1194818385
Provider Name (Legal Business Name): JENNIFER JOHNSON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 E FRONT AVE
STOCKTON IL
61085-1444
US

IV. Provider business mailing address

3663 S WILLOW RD
STOCKTON IL
61085-9516
US

V. Phone/Fax

Practice location:
  • Phone: 815-947-2215
  • Fax:
Mailing address:
  • Phone: 815-858-5494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070013008
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: