Provider Demographics
NPI:1255391884
Name:RUTHERFORD, JILLIAN PENNELL (PA-C)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:PENNELL
Last Name:RUTHERFORD
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 1:1850 EL CAMINO REAL STE 200
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3102
Mailing Address - Country:US
Mailing Address - Phone:650-697-2431
Mailing Address - Fax:650-697-3659
Practice Address - Street 1:2 LOWER RAGSDALE DR STE 160
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-5840
Practice Address - Country:US
Practice Address - Phone:831-717-4687
Practice Address - Fax:831-901-3160
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003965363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P44259Medicare UPIN
8802052Medicare ID - Type Unspecified