Provider Demographics
NPI:1063855567
Name:SHILLINGFORD, JAMAL
Entity Type:Individual
Prefix:
First Name:JAMAL
Middle Name:
Last Name:SHILLINGFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-272-5063
Mailing Address - Fax:
Practice Address - Street 1:2 BON AIR RD STE 120
Practice Address - Street 2:
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-1142
Practice Address - Country:US
Practice Address - Phone:415-927-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-15
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY51177207XS0117X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300013826Medicaid