Provider Demographics
NPI:1710641709
Name:SANTIAGO PEREZ, JACKELINE
Entity Type:Individual
Prefix:
First Name:JACKELINE
Middle Name:
Last Name:SANTIAGO PEREZ
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 1:8169 CONDOMINIO SAN VICENTE
Mailing Address - Street 2:SUITE 410 CALLE CONCORDIA
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717-7911
Mailing Address - Country:US
Mailing Address - Phone:787-460-5691
Mailing Address - Fax:
Practice Address - Street 1:1507 CALLE PROFESOR AUGUSTO RODRIGUEZ
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909
Practice Address - Country:US
Practice Address - Phone:787-705-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR014368183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician