Healthcare Provider Details

I. General information

NPI: 1720739899
Provider Name (Legal Business Name): JELISSE MATOS RENTA PSY.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JELISSE MATOS RENTA MED

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE MAYOR
PONCE PR
00730
US

IV. Provider business mailing address

202 CALLE PRINCIPE
COTO LAUREL PR
00780-3211
US

V. Phone/Fax

Practice location:
  • Phone: 787-905-5216
  • Fax:
Mailing address:
  • Phone: 787-905-5216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6671
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number6671
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6671
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: