Provider Demographics
NPI:1144413394
Name:WHAN, JILL LISTER (DPT)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:LISTER
Last Name:WHAN
Suffix:
Gender:F
Credentials:DPT
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 3686
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-1686
Mailing Address - Country:US
Mailing Address - Phone:310-896-8763
Mailing Address - Fax:310-697-0754
Practice Address - Street 1:326 S PACIFIC COAST HWY STE 100
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3768
Practice Address - Country:US
Practice Address - Phone:310-896-8763
Practice Address - Fax:310-697-0754
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33897174400000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist