Provider Demographics
NPI:1124225628
Name:LILLE, JEFFREY JAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:JAY
Last Name:LILLE
Suffix:
Gender:M
Credentials:PHD
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 1670
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93421-1670
Mailing Address - Country:US
Mailing Address - Phone:805-550-3162
Mailing Address - Fax:805-474-1521
Practice Address - Street 1:1264 HIGUERA ST
Practice Address - Street 2:SUITE 201
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3124
Practice Address - Country:US
Practice Address - Phone:805-550-3162
Practice Address - Fax:805-474-1521
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9831103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP9831AMedicare ID - Type Unspecified