Provider Demographics
NPI:1568413813
Name:SOMERVILLE, JILL L (PT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:L
Last Name:SOMERVILLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:L
Other - Last Name:DIDDIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:6263 POPLAR AVE
Mailing Address - Street 2:STE. 801
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-4701
Mailing Address - Country:US
Mailing Address - Phone:901-685-7227
Mailing Address - Fax:267-321-2079
Practice Address - Street 1:4601 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6305
Practice Address - Country:US
Practice Address - Phone:310-306-1478
Practice Address - Fax:310-306-6008
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29438225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT29438AMedicare PIN
CAW17215CMedicare PIN