Provider Demographics
NPI:1073656062
Name:HARRELL, JILL (MD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:HARRELL
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 1:6857 COLTON BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-1347
Mailing Address - Country:US
Mailing Address - Phone:510-339-3343
Mailing Address - Fax:
Practice Address - Street 1:350 30TH STREET, SUITE 530
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3426
Practice Address - Country:US
Practice Address - Phone:510-839-5564
Practice Address - Fax:510-839-1692
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65174174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A651740Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
CAH50082Medicare UPIN