Provider Demographics
NPI:1033359211
Name:SANTILLANO, JESSICA (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:SANTILLANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1668 DOMINICAN WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-1522
Mailing Address - Country:US
Mailing Address - Phone:831-464-9962
Mailing Address - Fax:831-476-1433
Practice Address - Street 1:1668 DOMINICAN WAY
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1522
Practice Address - Country:US
Practice Address - Phone:831-464-9962
Practice Address - Fax:831-476-1433
Is Sole Proprietor?:No
Enumeration Date:2009-02-27
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT186262208600000X
PAMD439752208600000X
CAA129837208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102481361Medicaid
PA102481361Medicaid