Provider Demographics
NPI:1790257566
Name:WANG, JILLIAN
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:WANG
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 1:419 TORRANCE BLVD
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:419 TORRANCE BLVD
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3326
Practice Address - Country:US
Practice Address - Phone:310-542-1856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty