Healthcare Provider Details

I. General information

NPI: 1417819160
Provider Name (Legal Business Name): JEANETTE CABANILLA PPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JEANETTE DE LA ROSA PPS

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1654 BUCKMAN SPRINGS RD
CAMPO CA
91906-2004
US

IV. Provider business mailing address

3305 BUCKMAN SPRINGS RD
PINE VALLEY CA
91962-4005
US

V. Phone/Fax

Practice location:
  • Phone: 619-473-9022
  • Fax:
Mailing address:
  • Phone: 619-473-9022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number250084946
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: