Healthcare Provider Details

I. General information

NPI: 1205139086
Provider Name (Legal Business Name): JILL EILEEN COUGHLIN R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2010
Last Update Date: 07/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3853 ROSECRANS ST
SAN DIEGO CA
92110-3115
US

IV. Provider business mailing address

3853 ROSECRANS ST
SAN DIEGO CA
92110-3115
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-8284
  • Fax: 619-542-4060
Mailing address:
  • Phone: 619-692-8284
  • Fax: 619-542-4060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number472395
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: