Healthcare Provider Details

I. General information

NPI: 1891984308
Provider Name (Legal Business Name): JILL MARIE OBRIEN LAC, D.O.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2007
Last Update Date: 10/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13660 N 94TH DR SUITE C-1
PEORIA AZ
85381-4836
US

IV. Provider business mailing address

13660 N 94TH DR SUITE C-1
PEORIA AZ
85381-4836
US

V. Phone/Fax

Practice location:
  • Phone: 623-933-1763
  • Fax: 623-933-1763
Mailing address:
  • Phone: 623-933-1763
  • Fax: 623-933-1763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number344
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: