Healthcare Provider Details

I. General information

NPI: 1255172284
Provider Name (Legal Business Name): JEAN C RODRIGUEZ VALLES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 10/01/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2431 BLVD LUIS A. FERRE SUITE 211
PONCE PR
00717
US

IV. Provider business mailing address

5888 LA MATILDE CALLE ARADO
PONCE PR
00728
US

V. Phone/Fax

Practice location:
  • Phone: 787-675-3733
  • Fax:
Mailing address:
  • Phone: 787-675-3733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number9172
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: