Provider Demographics
NPI:1043946148
Name:MARTINEZ CORREA, JAILENE
Entity Type:Individual
Prefix:
First Name:JAILENE
Middle Name:
Last Name:MARTINEZ CORREA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. LOS PINOS
Mailing Address - Street 2:CALLE CIPRES MEJICANO # 27
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00612
Mailing Address - Country:US
Mailing Address - Phone:787-405-4819
Mailing Address - Fax:
Practice Address - Street 1:CARR. 493 KM 0.9
Practice Address - Street 2:BO. CARRIZALES
Practice Address - City:HATILLO
Practice Address - State:PR
Practice Address - Zip Code:00659
Practice Address - Country:US
Practice Address - Phone:939-273-7555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR004359235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4881270OtherDRIVER LICENSE