Provider Demographics
NPI:1184381840
Name:REBOLLO LOPEZ, JACKELINE (MS)
Entity type:Individual
Prefix:
First Name:JACKELINE
Middle Name:
Last Name:REBOLLO LOPEZ
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB SANTAMERICA CALLE MICHIGAN APT 15014
Mailing Address - Street 2:APT 121
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00780
Mailing Address - Country:US
Mailing Address - Phone:787-628-9163
Mailing Address - Fax:
Practice Address - Street 1:TERRENOS DE SAN LUCAS
Practice Address - Street 2:CARR 14
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00780
Practice Address - Country:US
Practice Address - Phone:787-628-9163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-17
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1787225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor