Provider Demographics
NPI:1508684697
Name:CARRILLO, JESSICA KEAKEALANI
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:KEAKEALANI
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 1:1532 RANCHO LN
Mailing Address - Street 2:
Mailing Address - City:NORCO
Mailing Address - State:CA
Mailing Address - Zip Code:92860-2325
Mailing Address - Country:US
Mailing Address - Phone:949-606-4057
Mailing Address - Fax:
Practice Address - Street 1:148 N 8TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-2418
Practice Address - Country:US
Practice Address - Phone:949-606-4057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-28
Last Update Date:2024-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program