Provider Demographics
NPI:1134201627
Name:MACKINNON, JILL DOUGAL (MD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:DOUGAL
Last Name:MACKINNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 DWIGHT WAY
Mailing Address - Street 2:2ND FLOOR - ROOM # 2350
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-2608
Mailing Address - Country:US
Mailing Address - Phone:510-204-4738
Mailing Address - Fax:510-204-5892
Practice Address - Street 1:2001 DWIGHT WAY
Practice Address - Street 2:2ND FLOOR - ROOM # 2350
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-2608
Practice Address - Country:US
Practice Address - Phone:510-204-4738
Practice Address - Fax:510-204-5892
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67976204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G679760OtherMEDI-CAL
CA00G679760OtherMEDI-CAL