Basic Information
| Provider Information | |||||||||
| NPI: | 1700215217 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARRILLO | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYNE | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 223 MARKETVIEW | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926021689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143158871 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5762 BOLSA AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | HUNTINGTON BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926491172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142922322 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2013 | ||||||||
| LastUpdateDate: | 11/05/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-13-13534 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.