Provider Demographics
NPI:1285222398
Name:CARBALLO, JESSICA SUSAN (CNM)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUSAN
Last Name:CARBALLO
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:SUSAN
Other - Last Name:MANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:390 N LOOP RD
Mailing Address - Street 2:
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BLDG 390 N LOOP RD
Practice Address - Street 2:
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310
Practice Address - Country:US
Practice Address - Phone:760-383-5155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60857557163WM0102X
WAAP61176629367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn