Provider Demographics
NPI:1376649681
Name:CORREA, JESSICA IVELLISE (RPHTECH)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:IVELLISE
Last Name:CORREA
Suffix:
Gender:F
Credentials:RPHTECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 CALLE SOLEDAD
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745-2934
Mailing Address - Country:US
Mailing Address - Phone:787-887-2602
Mailing Address - Fax:
Practice Address - Street 1:CARR 3 KM 28.8
Practice Address - Street 2:
Practice Address - City:RIO GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00745
Practice Address - Country:US
Practice Address - Phone:787-887-2602
Practice Address - Fax:787-809-8398
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4573183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4573OtherPHARMACY TECH. LICENSE