Provider Demographics
NPI:1073237715
Name:CARABALLO, JEANETTE (CRSS)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:CARABALLO
Suffix:
Gender:F
Credentials:CRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3249 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-4360
Mailing Address - Country:US
Mailing Address - Phone:773-758-8912
Mailing Address - Fax:773-282-6698
Practice Address - Street 1:3249 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4360
Practice Address - Country:US
Practice Address - Phone:773-758-8912
Practice Address - Fax:773-282-6698
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILP00289175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist