Healthcare Provider Details

I. General information

NPI: 1265150486
Provider Name (Legal Business Name): JENNIFER JAZMIN CARRILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2022
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5115 DUDLEY BLVD
MCCLELLAN CA
95652-1024
US

IV. Provider business mailing address

3186 AIRWAY AVE STE A
COSTA MESA CA
92626-4650
US

V. Phone/Fax

Practice location:
  • Phone: 916-566-1600
  • Fax:
Mailing address:
  • Phone: 714-881-0427
  • Fax: 714-327-0673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: