Provider Demographics
NPI:1295702348
Name:BOSQUE OLIVAN, JESUS M (PHD)
Entity type:Individual
Prefix:DR
First Name:JESUS
Middle Name:M
Last Name:BOSQUE OLIVAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 MUNOZ RIVERA AVE
Mailing Address - Street 2:STE 500
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00925-2718
Mailing Address - Country:US
Mailing Address - Phone:787-756-5747
Mailing Address - Fax:787-756-5747
Practice Address - Street 1:1007 MUNOZ RIVERA AVE
Practice Address - Street 2:STE 500
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00925-2718
Practice Address - Country:US
Practice Address - Phone:787-756-5747
Practice Address - Fax:787-756-5747
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR00784103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRS32043Medicare UPIN
PR087670Medicare ID - Type Unspecified