Provider Demographics
NPI:1912190638
Name:DEHARO, JILL JUDE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:JUDE
Last Name:DEHARO
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 1:4760 W SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6063
Mailing Address - Country:US
Mailing Address - Phone:310-729-2465
Mailing Address - Fax:
Practice Address - Street 1:4760 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6063
Practice Address - Country:US
Practice Address - Phone:310-729-2465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21360363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant