Provider Demographics
NPI:1184963852
Name:NILLO, JEROME (RPT)
Entity type:Individual
Prefix:MR
First Name:JEROME
Middle Name:
Last Name:NILLO
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 FOSTER CITY BLVD APT C
Mailing Address - Street 2:
Mailing Address - City:FOSTER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94404-2341
Mailing Address - Country:US
Mailing Address - Phone:650-303-8228
Mailing Address - Fax:
Practice Address - Street 1:1049 FOSTER CITY BLVD., APT C
Practice Address - Street 2:
Practice Address - City:FOSTER CITY
Practice Address - State:CA
Practice Address - Zip Code:94404
Practice Address - Country:US
Practice Address - Phone:650-303-8228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36558225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist