Healthcare Provider Details

I. General information

NPI: 1780755405
Provider Name (Legal Business Name): JILL MARIE SULLIVAN PHYSICAL THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S LAFAYETTE ST
SOUTH LYON MI
48178-1407
US

IV. Provider business mailing address

59075 TRAVIS RD
NEW HUDSON MI
48165-9578
US

V. Phone/Fax

Practice location:
  • Phone: 248-486-1110
  • Fax: 248-486-3318
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501003385
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: