Healthcare Provider Details

I. General information

NPI: 1659295673
Provider Name (Legal Business Name): GENESIS PAMELA SURIEL JAQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69 SEGUNDO RUIZ BELVIS
SAN JUAN PR
00917
US

IV. Provider business mailing address

69 SEGUNDO RUIZ BELVIS
SAN JUAN PR
00917
US

V. Phone/Fax

Practice location:
  • Phone: 787-210-1207
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number009201
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: