Provider Demographics
NPI:1790390185
Name:WILSON, JILL M (RRT, RCP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:RRT, RCP
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:M
Other - Last Name:BALTHAZAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RRT, RCP
Mailing Address - Street 1:588 CALIENTE AVE
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-5355
Mailing Address - Country:US
Mailing Address - Phone:925-413-2863
Mailing Address - Fax:
Practice Address - Street 1:39400 PASEO PADRE PKWY
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2310
Practice Address - Country:US
Practice Address - Phone:510-248-3747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA154702279P3900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2279P3900XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredNeonatal/Pediatrics