Provider Demographics
NPI:1114540754
Name:FONSECA RIVERA, JESENIA (MSW)
Entity Type:Individual
Prefix:
First Name:JESENIA
Middle Name:
Last Name:FONSECA RIVERA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:STREET CORNER 46
Mailing Address - Street 2:
Mailing Address - City:ARROYO
Mailing Address - State:PR
Mailing Address - Zip Code:00714
Mailing Address - Country:US
Mailing Address - Phone:787-839-4150
Mailing Address - Fax:787-839-3989
Practice Address - Street 1:HC 63 BOX 3939
Practice Address - Street 2:
Practice Address - City:PATILLAS
Practice Address - State:PR
Practice Address - Zip Code:00723-9648
Practice Address - Country:US
Practice Address - Phone:939-280-8833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-18
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11002104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR11002OtherLICENCE