Provider Demographics
NPI:1194740696
Name:JOHNSTON, JILL MARIE (PT)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:MARIE
Last Name:JOHNSTON
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 1:1622 TALL GRASS CIR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2657
Mailing Address - Country:US
Mailing Address - Phone:262-521-9497
Mailing Address - Fax:
Practice Address - Street 1:W359N5002 BROWN ST
Practice Address - Street 2:SUITE B
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3366
Practice Address - Country:US
Practice Address - Phone:262-366-9340
Practice Address - Fax:262-560-4100
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3572225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist