Provider Demographics
NPI:1063466258
Name:GRODZINSKI, JAIME
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:
Last Name:GRODZINSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SAN JUAN HEALTH CTR
Mailing Address - Street 2:150 DE DIEGO AVE SUITE 710
Mailing Address - City:SANTURCE
Mailing Address - State:PR
Mailing Address - Zip Code:00907-2300
Mailing Address - Country:US
Mailing Address - Phone:787-724-5831
Mailing Address - Fax:787-724-5109
Practice Address - Street 1:SAN JUAN HEALTH CTR
Practice Address - Street 2:150 DE DIEGO AVE SUITE 710
Practice Address - City:SANTURCE
Practice Address - State:PR
Practice Address - Zip Code:00907-2300
Practice Address - Country:US
Practice Address - Phone:787-724-5831
Practice Address - Fax:787-724-5109
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1903103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR20721Medicare ID - Type Unspecified