Provider Demographics
NPI:1962992396
Name:STONE, JILLIAN
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:STONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:
Other - Last Name:GILPATRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24992 MAMMOTH CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2542
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:151 KALMUS DR STE K2
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5975
Practice Address - Country:US
Practice Address - Phone:888-395-4484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA55865363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA55865OtherPAB