Healthcare Provider Details

I. General information

NPI: 1154019149
Provider Name (Legal Business Name): JACKELINE CARABALLO RIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 04/27/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

URB COCOBEACH 210 CALLE MANATI
RIO GRANDE PR
00745
US

IV. Provider business mailing address

URB COCOBEACH 210 CALLE MANATI CALLE MANATI
RIO GRANDE PR
00745
US

V. Phone/Fax

Practice location:
  • Phone: 787-516-6607
  • Fax:
Mailing address:
  • Phone: 787-516-6607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6187
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6187
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: