Provider Demographics
NPI:1447643747
Name:GOMEZ, JILLIEN
Entity type:Individual
Prefix:
First Name:JILLIEN
Middle Name:
Last Name:GOMEZ
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 1:2708 HARVEY WAY
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-3735
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2708 HARVEY WAY
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-3735
Practice Address - Country:US
Practice Address - Phone:323-767-4084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-10
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15-162246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant