Provider Demographics
NPI:1508123951
Name:RIVERA ROMAN, JESSICA M
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:RIVERA ROMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX
Mailing Address - Street 2:30651
Mailing Address - City:SAN JUAN
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00929
Mailing Address - Country:UM
Mailing Address - Phone:787-349-9417
Mailing Address - Fax:
Practice Address - Street 1:CORPORACION DEL FONDO DEL SEGURO DEL ESTADO
Practice Address - Street 2:CARR #3 65TH INFANTERIA
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00985
Practice Address - Country:US
Practice Address - Phone:787-349-9417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR003542183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4220980OtherDRIVERS LICENCE