Healthcare Provider Details

I. General information

NPI: 1770092785
Provider Name (Legal Business Name): JEARLEAN RUIZ MARIN PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2017
Last Update Date: 09/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 OLD MOULTRIE RD STE 101
ST AUGUSTINE FL
32086-5106
US

IV. Provider business mailing address

3425 S RAVELLO DR
SAINT AUGUSTINE FL
32092-3486
US

V. Phone/Fax

Practice location:
  • Phone: 863-709-8110
  • Fax:
Mailing address:
  • Phone: 939-717-2705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number9939
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: