Provider Demographics
NPI:1528434313
Name:TANNER, JILL (PA)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2421 MICHELTORENA ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-2531
Mailing Address - Country:US
Mailing Address - Phone:818-371-1311
Mailing Address - Fax:
Practice Address - Street 1:99 N LA CIENEGA BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2222
Practice Address - Country:US
Practice Address - Phone:310-289-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-15
Last Update Date:2015-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52731363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant