Basic Information
| Provider Information | |||||||||
| NPI: | 1457516171 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIDCUMB | ||||||||
| FirstName: | JILLIAN | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 931 RIDGE RD | ||||||||
| Address2: | SUITE G | ||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463211755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198362800 | ||||||||
| FaxNumber: | 2198362897 | ||||||||
| Practice Location | |||||||||
| Address1: | 1505 US HIGHWAY 41 | ||||||||
| Address2: | SUITE A20 | ||||||||
| City: | SCHERERVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463751321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193225560 | ||||||||
| FaxNumber: | 2193221549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2008 | ||||||||
| LastUpdateDate: | 05/04/2011 | ||||||||
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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 | 070-016483 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 05010452A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.