Healthcare Provider Details

I. General information

NPI: 1194165670
Provider Name (Legal Business Name): JAMELA SANTOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2013
Last Update Date: 12/08/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 LEON GUERRERO DRIVE
TUMON GU
96913
US

IV. Provider business mailing address

104 FEDERICO ST
MANGILAO GU
96913-5768
US

V. Phone/Fax

Practice location:
  • Phone: 671-646-5748
  • Fax:
Mailing address:
  • Phone: 671-646-5748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF-123
License Number StateGU
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-123
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: