Healthcare Provider Details

I. General information

NPI: 1609209709
Provider Name (Legal Business Name): JILLIAN JENELL CERTO DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2013
Last Update Date: 08/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23123 CAMDEN WAY
CALIFORNIA MD
20619-2446
US

IV. Provider business mailing address

11855 HG TRUEMAN RD
LUSBY MD
20657-2855
US

V. Phone/Fax

Practice location:
  • Phone: 301-862-5177
  • Fax:
Mailing address:
  • Phone: 410-326-3432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number24643
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: