Provider Demographics
NPI:1548223209
Name:CARRILLO, JENNIFER (ATC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:NICKERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:26531 VIA SACRAMENTO # A
Mailing Address - Street 2:#A
Mailing Address - City:CAPISTRANO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92624-1338
Mailing Address - Country:US
Mailing Address - Phone:310-409-5050
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY DR
Practice Address - Street 2:ATHLETIC DEPARTMENT
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-8081
Practice Address - Country:US
Practice Address - Phone:310-409-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer