Provider Demographics
NPI:1669990503
Name:CARRILLO, JOSE EDUARDO (MA, QMHP)
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:EDUARDO
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:MA, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 CARSON LOOP
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-1632
Mailing Address - Country:US
Mailing Address - Phone:408-206-9385
Mailing Address - Fax:
Practice Address - Street 1:420 NE 5TH ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-4603
Practice Address - Country:US
Practice Address - Phone:503-434-7462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health