Provider Demographics
NPI:1396306148
Name:PIERSON, JILLIAN (PA-C)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:PIERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:
Other - Last Name:KELTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:64 AVON RD
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:94707-1302
Mailing Address - Country:US
Mailing Address - Phone:570-242-6520
Mailing Address - Fax:
Practice Address - Street 1:13855 E 14TH ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2611
Practice Address - Country:US
Practice Address - Phone:510-357-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56934363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant