Provider Demographics
NPI:1639454150
Name:ROMAN, JESSICA DEL CARMEN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DEL CARMEN
Last Name: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 1:176 CALLE ZARZUELA
Mailing Address - Street 2:URB. PALACIOS REALES
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953-4916
Mailing Address - Country:US
Mailing Address - Phone:787-366-5140
Mailing Address - Fax:
Practice Address - Street 1:176 CALLE ZARZUELA
Practice Address - Street 2:URB. PALACIOS REALES
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953-4916
Practice Address - Country:US
Practice Address - Phone:787-366-5140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-16
Last Update Date:2011-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1252133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered