Provider Demographics
NPI:1508684697
Name:CARRILLO, JESSICA KEAKEALANI (DPM)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:KEAKEALANI
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:DPM
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 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5189
Practice Address - Country:US
Practice Address - Phone:800-836-7536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-28
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC007586213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine