Provider Demographics
NPI:1093572471
Name:MIRANDA RODRIGUEZ, JAILENE NICOLE (MS)
Entity Type:Individual
Prefix:
First Name:JAILENE
Middle Name:NICOLE
Last Name:MIRANDA RODRIGUEZ
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:D2 EXT EL TAINO
Mailing Address - Street 2:
Mailing Address - City:SANTA ISABEL
Mailing Address - State:PR
Mailing Address - Zip Code:00757-2108
Mailing Address - Country:US
Mailing Address - Phone:939-350-3042
Mailing Address - Fax:
Practice Address - Street 1:D2 EXT EL TAINO
Practice Address - Street 2:
Practice Address - City:SANTA ISABEL
Practice Address - State:PR
Practice Address - Zip Code:00757-2108
Practice Address - Country:US
Practice Address - Phone:939-350-3042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6515103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling