Provider Demographics
NPI:1619526951
Name:NAMBO, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:NAMBO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:RODRIGUEZ CARRILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1026 W EL NORTE PKWY # 166
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-3341
Mailing Address - Country:US
Mailing Address - Phone:619-254-5281
Mailing Address - Fax:
Practice Address - Street 1:541 LEDGE ST
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-2840
Practice Address - Country:US
Practice Address - Phone:619-254-5281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2025-06-27
Deactivation Date:2025-06-04
Deactivation Code:
Reactivation Date:2025-06-25
Provider Licenses
StateLicense IDTaxonomies
CARBT-19-97827106S00000X
CA117366104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician