MEDICARE: MRS. JILL DANIELLE KOPENY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	5590	CA

General Provider Information

NPI Number	:	1104111681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JILL DANIELLE KOPENY

Provider Business Mailing Address
First Line	:	9 MISSION ST
Second Line	:
City	:	RANCHO SANTA MARGARITA
State	:	CA
Zip	:	92688-3103
Country	:	US
Telephone Number	:	949-635-9788
Fax Number	:

Provider Business Practice Location Address
First Line	:	777 CORPORATE DR
Second Line	:	STE 160
City	:	LADERA RANCH
State	:	CA
Zip	:	92694-2135
Country	:	US
Telephone Number	:	949-472-2242
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2011
Last Update Date	:	06/13/2011

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