MEDICARE: DR. JEFFREY JAY LILLE PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY9831	CA

General Provider Information

NPI Number	:	1124225628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY JAY LILLE PHD

Provider Business Mailing Address
First Line	:	PO BOX 1670
Second Line	:
City	:	ARROYO GRANDE
State	:	CA
Zip	:	93421-1670
Country	:	US
Telephone Number	:	805-550-3162
Fax Number	:	805-474-1521

Provider Business Practice Location Address
First Line	:	1264 HIGUERA ST
Second Line	:	SUITE 201
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-3124
Country	:	US
Telephone Number	:	805-550-3162
Fax Number	:	805-474-1521

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2007
Last Update Date	:	06/24/2020

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