Provider Demographics
NPI:1538680558
Name:MEDINA MEDINA, JAIME (MSW, JD)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:MEDINA MEDINA
Suffix:
Gender:M
Credentials:MSW, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CII 32 JARDINES DEL CARIBE
Mailing Address - Street 2:FF33
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00728-2609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CII 32 JARDINES DEL CARIBE
Practice Address - Street 2:FF33
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00728-2609
Practice Address - Country:US
Practice Address - Phone:787-290-0022
Practice Address - Fax:787-842-5342
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3685104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR3685OtherSOCIAL WORK PERMANENT LICENCE