Healthcare Provider Details

I. General information

NPI: 1366092520
Provider Name (Legal Business Name): JASMINE M CARRILLO-BAUTISTA ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PINE AVE
LONG BEACH CA
90813-3124
US

IV. Provider business mailing address

901 W VICTORIA ST STE F&G
COMPTON CA
90220-5807
US

V. Phone/Fax

Practice location:
  • Phone: 562-595-1159
  • Fax:
Mailing address:
  • Phone: 310-669-9510
  • Fax: 310-669-9501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW127530
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: