Provider Demographics
NPI:1417230210
Name:IRIZARRY, JISELLY (MSW)
Entity Type:Individual
Prefix:MS
First Name:JISELLY
Middle Name:
Last Name:IRIZARRY
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 1:5 CALLE 10
Mailing Address - Street 2:NUEVA VIDA, EL TUQUE
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00730-3318
Mailing Address - Country:US
Mailing Address - Phone:787-605-8110
Mailing Address - Fax:
Practice Address - Street 1:CALLE SOL # 120
Practice Address - Street 2:CENTRO PONCENO DE AUTISMO
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00730-4810
Practice Address - Country:US
Practice Address - Phone:787-284-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR108791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR10879OtherMSW LICENSE