Healthcare Provider Details

I. General information

NPI: 1871628958
Provider Name (Legal Business Name): JANNETTE ALICEA M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR. 167 KM. 14.6 BO. BUENA VISTA
BAYAMON PR
00957
US

IV. Provider business mailing address

PO BOX 1113
BAYAMON PR
00960-1113
US

V. Phone/Fax

Practice location:
  • Phone: 787-730-5076
  • Fax: 787-730-5076
Mailing address:
  • Phone: 787-730-5076
  • Fax: 787-730-5076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1845
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: