Provider Demographics
NPI:1134630189
Name:MITCHELL, JILLIAN (PT)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:
Other - Last Name:KITTERICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:408 HIGUERA ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6135
Mailing Address - Country:US
Mailing Address - Phone:805-788-0805
Mailing Address - Fax:805-788-0845
Practice Address - Street 1:4435 EASTGATE MALL STE 120
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1980
Practice Address - Country:US
Practice Address - Phone:858-587-8669
Practice Address - Fax:858-587-8675
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP20090225100000X
CAPT293841225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist