Provider Demographics
NPI:1508274986
Name:ALFONSO, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ALFONSO
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:URB. ALTRAS DEL RIO CALLE 5 A11
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00959
Mailing Address - Country:US
Mailing Address - Phone:787-914-1130
Mailing Address - Fax:
Practice Address - Street 1:D6 CLL EBANO
Practice Address - Street 2:COND PARQUE DE SAN PATRICIO
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00968
Practice Address - Country:US
Practice Address - Phone:787-914-1130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
PR006316103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1307576Medicaid
MA1303295Medicaid
MAM18463OtherBLUE CROSS BLUE SHIELD
MAY10086Medicare PIN