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General NPI Number Information
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NPI Number | 1992807077
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Entity Type | Individual
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Provider Name | JACK LEROY GILLILAND M.D.
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Gender | Male
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Dates
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Enumeration Date | 09/01/2006
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Last Update Date | 01/18/2026
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Provider Practice Location Address
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Address Line | 7373 WEST LN
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City | STOCKTON
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State | CA
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Zip | 95210-3377
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Country | US
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Telephone | 209-476-3346
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Fax |
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Provider Business Mailing Address
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Address Line | 325 W TADDEI RD
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City | ACAMPO
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State | CA
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Zip | 95220-9654
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Country | US
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Telephone | 209-334-1424
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | G15491
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License Number State | CA
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