Provider Demographics
NPI:1174285795
Name:SANTILLAN GOMEZ, JAMILLETH
Entity Type:Individual
Prefix:
First Name:JAMILLETH
Middle Name:
Last Name:SANTILLAN GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 N TUSTIN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-7875
Mailing Address - Country:US
Mailing Address - Phone:855-581-0100
Mailing Address - Fax:
Practice Address - Street 1:1317 OAKDALE RD STE 610
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-3365
Practice Address - Country:US
Practice Address - Phone:855-581-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-11
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician