Provider Demographics
NPI:1104189687
Name:YOUSSEF, JILLAN
Entity Type:Individual
Prefix:
First Name:JILLAN
Middle Name:
Last Name:YOUSSEF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7215 FORESTER PL
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-5933
Mailing Address - Country:US
Mailing Address - Phone:626-623-9353
Mailing Address - Fax:
Practice Address - Street 1:16145 SIERRA LAKES PKWY
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1243
Practice Address - Country:US
Practice Address - Phone:909-356-9167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66981183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist