MEDICARE: MISS JILL O'BRIEN MS, ATC

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	2255A2300X	Athletic Trainer	729	OK

General Provider Information

NPI Number	:	1326384058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JILL O'BRIEN MS, ATC

Provider Business Mailing Address
First Line	:	12239 W WASHINGTON BLVD
Second Line	:	APT B
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-5518
Country	:	US
Telephone Number	:	805-801-0170
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 LMU DR
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-2650
Country	:	US
Telephone Number	:	310-338-2340
Fax Number	:	310-338-5191

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

Provider Enumeration Date	:	12/28/2012
Last Update Date	:	07/27/2020

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