Provider Demographics
NPI:1093133340
Name:DAVENPORT, JILLIAN RENEE (MD)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:RENEE
Last Name:DAVENPORT
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 1:7700 MORRO RD
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-4435
Mailing Address - Country:US
Mailing Address - Phone:805-466-6622
Mailing Address - Fax:805-461-0361
Practice Address - Street 1:7700 MORRO RD
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-4435
Practice Address - Country:US
Practice Address - Phone:805-466-6622
Practice Address - Fax:805-461-0361
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA140588208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics