Provider Demographics
NPI:1891592473
Name:SEMILLO, JONATHAN DAVID
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DAVID
Last Name:SEMILLO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10424 GRASS VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-4549
Mailing Address - Country:US
Mailing Address - Phone:209-938-7131
Mailing Address - Fax:
Practice Address - Street 1:10424 GRASS VALLEY CT
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-4549
Practice Address - Country:US
Practice Address - Phone:209-938-7131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-28
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer