MEDICARE: JENNIFER CARRILLO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1407457583
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER CARRILLO

Provider Business Mailing Address
First Line	:	1682 VIRGINIA AVE APT 1
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95116-2944
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1682 VIRGINIA AVE APT 1
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95116-2944
Country	:	US
Telephone Number	:	669-225-3459
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2020
Last Update Date	:	11/05/2020

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Directions to “ JENNIFER CARRILLO ” Practice Location

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