Provider Demographics
NPI:1194818385
Name:JOHNSON, JENNIFER (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JOHNSON
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 1:3663 S WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:IL
Mailing Address - Zip Code:61085-9516
Mailing Address - Country:US
Mailing Address - Phone:815-858-5494
Mailing Address - Fax:
Practice Address - Street 1:501 E FRONT AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:IL
Practice Address - Zip Code:61085-1444
Practice Address - Country:US
Practice Address - Phone:815-947-2215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013008225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist