Provider Demographics
NPI:1265277032
Name:ORTIZ, JACKELINE
Entity type:Individual
Prefix:
First Name:JACKELINE
Middle Name:
Last Name:ORTIZ
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 1:1413 CARR 2
Mailing Address - Street 2:
Mailing Address - City:BARCELONETA
Mailing Address - State:PR
Mailing Address - Zip Code:00617-3141
Mailing Address - Country:US
Mailing Address - Phone:787-970-8106
Mailing Address - Fax:787-970-8115
Practice Address - Street 1:PMB 725 BOX 4960
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00617
Practice Address - Country:US
Practice Address - Phone:787-970-8106
Practice Address - Fax:787-970-8115
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1419156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician