Healthcare Provider Details

I. General information

NPI: 1639794159
Provider Name (Legal Business Name): JANNELLE FELICIANO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVENIDA FIDALGO DIAZ #CL3 VIA EMILIA, VILLA FONTANA
CAROLINA PR
00983
US

IV. Provider business mailing address

CALLE DUKE #901 UNIVERSITY GARDENS APT. B- 3
SAN JUAN PR
00927-4834
US

V. Phone/Fax

Practice location:
  • Phone: 787-222-4820
  • Fax:
Mailing address:
  • Phone: 787-222-4820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3418
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: