Provider Demographics
NPI:1619526951
Name:RODRIGUEZ CARRILLO, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RODRIGUEZ CARRILLO
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 1:556 SHADYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-1426
Mailing Address - Country:US
Mailing Address - Phone:619-254-5281
Mailing Address - Fax:
Practice Address - Street 1:10174 OLD GROVE RD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1652
Practice Address - Country:US
Practice Address - Phone:858-444-8823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-19-97827106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician