Provider Demographics
NPI:1922348929
Name:CARRILLO, JENNIFER MARIE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:FLORES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14821 DANCER ST
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-1818
Mailing Address - Country:US
Mailing Address - Phone:626-733-7259
Mailing Address - Fax:
Practice Address - Street 1:10428 LOWER AZUSA RD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-1208
Practice Address - Country:US
Practice Address - Phone:626-255-6475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-27
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator