Healthcare Provider Details

I. General information

NPI: 1093133340
Provider Name (Legal Business Name): JILLIAN RENEE DAVENPORT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2014
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 STATION WAY STE B
ARROYO GRANDE CA
93420-3383
US

IV. Provider business mailing address

230 STATION WAY STE B
ARROYO GRANDE CA
93420-3383
US

V. Phone/Fax

Practice location:
  • Phone: 805-473-3262
  • Fax: 805-473-3707
Mailing address:
  • Phone: 805-473-3262
  • Fax: 805-473-3707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA140588
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: