Provider Demographics
NPI:1417009911
Name:SANTILLAN, JENNIFER S (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:SANTILLAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16253 MAGNOLIA WAY
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-5693
Mailing Address - Country:US
Mailing Address - Phone:909-609-1520
Mailing Address - Fax:909-829-1507
Practice Address - Street 1:16253 MAGNOLIA WAY
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-5693
Practice Address - Country:US
Practice Address - Phone:909-609-1520
Practice Address - Fax:909-829-1507
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28453225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT284530Medicare ID - Type Unspecified