Provider Demographics
NPI:1669218491
Name:DE JESUS-MARRERO, AMANDA PAOLA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:PAOLA
Last Name:DE JESUS-MARRERO
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 1:89 RES VILLA VALLE VERDE # K
Mailing Address - Street 2:
Mailing Address - City:ADJUNTAS
Mailing Address - State:PR
Mailing Address - Zip Code:00601-2112
Mailing Address - Country:US
Mailing Address - Phone:939-460-7761
Mailing Address - Fax:
Practice Address - Street 1:89 RES VILLA VALLE VERDE # K
Practice Address - Street 2:
Practice Address - City:ADJUNTAS
Practice Address - State:PR
Practice Address - Zip Code:00601-2112
Practice Address - Country:US
Practice Address - Phone:939-460-7761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7939103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool