Provider Demographics
NPI:1942510193
Name:DORTA-DIAZ, JEANNETTE A (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEANNETTE
Middle Name:A
Last Name:DORTA-DIAZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19304
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00910-9304
Mailing Address - Country:US
Mailing Address - Phone:787-644-4611
Mailing Address - Fax:787-722-4731
Practice Address - Street 1:AVE. DEGETAU BLOQUE D # 7
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-644-4611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2056103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical