Provider Demographics
NPI:1538443601
Name:CARRILLO, JESUS (PT)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 LOCUST PL
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-1212
Mailing Address - Country:US
Mailing Address - Phone:973-413-9936
Mailing Address - Fax:
Practice Address - Street 1:1070 CLIFTON AVE
Practice Address - Street 2:SUITE 1A
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3619
Practice Address - Country:US
Practice Address - Phone:973-246-6565
Practice Address - Fax:973-883-0140
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00474700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist