Provider Demographics
NPI:1588148993
Name:RALSTON, JILLIAN (OD)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:RALSTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:
Other - Last Name:NIRENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:112 W MCDOWELL ROAD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85003
Mailing Address - Country:US
Mailing Address - Phone:602-254-3169
Mailing Address - Fax:
Practice Address - Street 1:112 W MCDOWELL ROAD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85003
Practice Address - Country:US
Practice Address - Phone:602-254-3169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002309152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist