Healthcare Provider Details

I. General information

NPI: 1720993090
Provider Name (Legal Business Name): JESSICA CARRILLO GARTEIZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14855 SW 36TH TER
MIAMI FL
33185-3917
US

IV. Provider business mailing address

14855 SW 36TH TER
MIAMI FL
33185-3917
US

V. Phone/Fax

Practice location:
  • Phone: 786-205-0464
  • Fax:
Mailing address:
  • Phone: 786-205-0464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11049961
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: