Basic Information
| Provider Information | |||||||||
| NPI: | 1437111283 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEUTHOLD | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | ATC, L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7575 ELYRIA RD | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442568963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303219607 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2640 W MARKET ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | FAIRLAWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443334202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308692635 | ||||||||
| FaxNumber: | 3308698315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 2389 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.