Provider Demographics
NPI:1598783086
Name:IRELAND, JILL MARIE (PA C)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:IRELAND
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28431 SILVERKING TRAIL
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91390
Mailing Address - Country:US
Mailing Address - Phone:661-296-6194
Mailing Address - Fax:
Practice Address - Street 1:200 S WELLS RD STE 100
Practice Address - Street 2:CLINICAS DEL CAMINO REAL INC
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93004
Practice Address - Country:US
Practice Address - Phone:805-659-1740
Practice Address - Fax:805-659-9959
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16461363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P67778Medicare UPIN
W3731Medicare ID - Type Unspecified