Healthcare Provider Details

I. General information

NPI: 1811891021
Provider Name (Legal Business Name): YANITZMARIE POLANCO JORDAN MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2026
Last Update Date: 10/03/2026
Certification Date: 10/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

G24 CALLE PRINCIPAL
FAJARDO PR
00738-3774
US

IV. Provider business mailing address

19 CALLE CANELA
CEIBA PR
00735-4010
US

V. Phone/Fax

Practice location:
  • Phone: 919-348-2717
  • Fax:
Mailing address:
  • Phone: 919-397-3828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number9135
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: