Provider Demographics
NPI:1649395997
Name:DYLLA, JACQUELYN M
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:M
Last Name:DYLLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 MARENGO ST
Mailing Address - Street 2:#102
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1036
Mailing Address - Country:US
Mailing Address - Phone:213-821-2559
Mailing Address - Fax:213-821-1499
Practice Address - Street 1:3301 S HOOVER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0001
Practice Address - Country:US
Practice Address - Phone:213-740-0215
Practice Address - Fax:213-821-1499
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT195622251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT19562OtherLICENSE