Provider Demographics
NPI:1366552200
Name:MATHIS, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:MATHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5155 SHADY GROVE RD
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-4730
Mailing Address - Country:US
Mailing Address - Phone:770-205-3939
Mailing Address - Fax:
Practice Address - Street 1:540 LAKE CENTER PKWY
Practice Address - Street 2:SUITE 107
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-7727
Practice Address - Country:US
Practice Address - Phone:770-205-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT004825OtherLICENSE #