Provider Demographics
NPI:1679373781
Name:CARRILLO, JAZMIN (SUDRC)
Entity type:Individual
Prefix:
First Name:JAZMIN
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:
Credentials:SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25928 ELDRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-2650
Mailing Address - Country:US
Mailing Address - Phone:510-342-6858
Mailing Address - Fax:
Practice Address - Street 1:1580 CHABOT CT
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-2423
Practice Address - Country:US
Practice Address - Phone:510-783-8708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20960101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty