Basic Information
Provider Information
NPI: 1003013269
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CHELSON
FirstName: JILLIAN
MiddleName: MARGARET
NamePrefix: MS.
NameSuffix:  
Credential: PA-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 31 DUNSLEE WAY
Address2:  
City: SCOTTS VALLEY
State: CA
PostalCode: 950663427
CountryCode: US
TelephoneNumber: 4157131249
FaxNumber:  
Practice Location
Address1: 2222 BANCROFT EXT
Address2:  
City: BERKELEY
State: CA
PostalCode: 947204300
CountryCode: US
TelephoneNumber: 5106422000
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/29/2007
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363A00000X14574CAY Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 

No ID Information.


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