Provider Demographics
NPI:1316038367
Name:MCCARTY, JILLANNE W (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JILLANNE
Middle Name:W
Last Name:MCCARTY
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1280 S VICTORIA AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-6504
Mailing Address - Country:US
Mailing Address - Phone:805-658-3937
Mailing Address - Fax:805-658-3930
Practice Address - Street 1:1280 S VICTORIA AVE STE 160
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-6504
Practice Address - Country:US
Practice Address - Phone:805-658-3937
Practice Address - Fax:805-658-3930
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64125174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA010622759OtherTAX ID
CAG64125OtherSTATE LIC.
CA00G641250Medicaid
CABM1576531OtherDEA
CAG64125Medicare PIN
CAF31919Medicare UPIN