Provider Demographics
NPI:1811444805
Name:FERNANDO, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:FERNANDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2119 ROCKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-3705
Mailing Address - Country:US
Mailing Address - Phone:805-231-1531
Mailing Address - Fax:
Practice Address - Street 1:2119 ROCKDALE AVE
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-3705
Practice Address - Country:US
Practice Address - Phone:805-231-1531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YA0400X
CA7480101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional