Basic Information
| Provider Information | |||||||||
| NPI: | 1407936172 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONGFELLOW | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5936 N KEYSTONE AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462202458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172578340 | ||||||||
| FaxNumber: | 3172578361 | ||||||||
| Practice Location | |||||||||
| Address1: | 5936 N KEYSTONE AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462202458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172578340 | ||||||||
| FaxNumber: | 3172578361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05009105A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000000487333 | 01 | THERAPIST ANTHEM PROV | OTHER |