Provider Demographics
NPI:1689078594
Name:ROSADO, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:ROSADO
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 1:15009 CALLE HUCAR
Mailing Address - Street 2:PASEOS DE JACARANDA
Mailing Address - City:SANTA ISABEL
Mailing Address - State:PR
Mailing Address - Zip Code:00757
Mailing Address - Country:US
Mailing Address - Phone:787-842-0175
Mailing Address - Fax:787-259-8185
Practice Address - Street 1:1046 AVE HOSTOS GALERIA DEL SUR BLDG
Practice Address - Street 2:SUITE 200
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716
Practice Address - Country:US
Practice Address - Phone:787-842-0170
Practice Address - Fax:787-259-8185
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-21
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1757103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1757OtherLICENSE