=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417819160
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEANETTE CABANILLA PPS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2025
-----------------------------------------------------
Last Update Date | 12/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1654 BUCKMAN SPRINGS RD
-----------------------------------------------------
City | CAMPO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91906-2004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-473-9022
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3305 BUCKMAN SPRINGS RD
-----------------------------------------------------
City | PINE VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91962-4005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-473-9022
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 250084946
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------