Provider Demographics
NPI:1528466893
Name:WILTFONG, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:WILTFONG
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 1:14342 126TH AVE NE
Mailing Address - Street 2:A302
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-1537
Mailing Address - Country:US
Mailing Address - Phone:206-947-2898
Mailing Address - Fax:
Practice Address - Street 1:9441 LBJ FWY
Practice Address - Street 2:SUITE 602
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-4545
Practice Address - Country:US
Practice Address - Phone:469-249-1887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA282N00000X282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital