Provider Demographics
NPI:1427522317
Name:HERREN, JILL MARIE (LPTA)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:HERREN
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 CANTERBURY RD
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-5027
Mailing Address - Country:US
Mailing Address - Phone:423-276-5258
Mailing Address - Fax:
Practice Address - Street 1:100 NETHERLAND LN
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-7245
Practice Address - Country:US
Practice Address - Phone:423-245-0360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1792225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty