Provider Demographics
NPI:1942540067
Name:DE JESUS SANTIAGO, ILEANA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ILEANA
Middle Name:
Last Name:DE JESUS SANTIAGO
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 1:1626 CALLE INDO
Mailing Address - Street 2:URB. EL CEREZAL
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-3031
Mailing Address - Country:US
Mailing Address - Phone:787-342-2948
Mailing Address - Fax:
Practice Address - Street 1:1626 CALLE INDO
Practice Address - Street 2:URB. EL CEREZAL
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-3031
Practice Address - Country:US
Practice Address - Phone:787-342-2948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR004677103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical