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General NPI Number Information
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NPI Number | 1508684697
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Entity Type | Individual
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Provider Name | JESSICA KEAKEALANI CARRILLO DPM
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Gender | Female
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Dates
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Enumeration Date | 09/28/2024
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Last Update Date | 06/23/2025
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Provider Practice Location Address
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Address Line | 3401 N BROAD ST
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City | PHILADELPHIA
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State | PA
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Zip | 19140-5189
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Country | US
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Telephone | 800-836-7536
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Fax |
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Provider Business Mailing Address
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Address Line | 1532 RANCHO LN
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City | NORCO
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State | CA
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Zip | 92860-2325
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Country | US
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Telephone | 949-606-4057
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213EP1101X
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Taxonomy Name | Primary Podiatric Medicine Podiatrist
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License Number | SC007586
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | SC007586
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License Number State | PA
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