Provider Demographics
NPI:1922390897
Name:MINDICH, JESSICA LOGAN (TECHNICIAN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LOGAN
Last Name:MINDICH
Suffix:
Gender:F
Credentials:TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 GUARD RD
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00603-1304
Mailing Address - Country:US
Mailing Address - Phone:787-890-8477
Mailing Address - Fax:
Practice Address - Street 1:260 GUARD RD
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603-1304
Practice Address - Country:US
Practice Address - Phone:787-890-8477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB1978064146N00000X
CA247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic