Provider Demographics
NPI:1720817711
Name:CARRILLO, JENNIFER (OT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4900 ELK GROVE BLVD # 415
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-4188
Mailing Address - Country:US
Mailing Address - Phone:916-793-4797
Mailing Address - Fax:
Practice Address - Street 1:4900 ELK GROVE BLVD # 415
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-4188
Practice Address - Country:US
Practice Address - Phone:916-793-4797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12569225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist