Provider Demographics
NPI:1962220343
Name:CARRILLO, JAZMINE ALEXIS
Entity type:Individual
Prefix:
First Name:JAZMINE
Middle Name:ALEXIS
Last Name: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 1:1044 W BENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91722-2521
Mailing Address - Country:US
Mailing Address - Phone:626-384-0055
Mailing Address - Fax:
Practice Address - Street 1:4996 LA SIERRA AVE # 2612
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-2612
Practice Address - Country:US
Practice Address - Phone:951-525-3752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist