Provider Demographics
NPI:1588442347
Name:GHOLSON-HEARNS, JILL (PTA, PES)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:GHOLSON-HEARNS
Suffix:
Gender:F
Credentials:PTA, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6304 MARIETTA AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-5158
Mailing Address - Country:US
Mailing Address - Phone:219-545-8951
Mailing Address - Fax:
Practice Address - Street 1:2775 VILLAGE PT
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-0099
Practice Address - Country:US
Practice Address - Phone:219-304-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003488A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant