Provider Demographics
NPI:1669867321
Name:ORTIZ, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
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:HC 01 BOX 4445
Mailing Address - Street 2:
Mailing Address - City:COROZAL
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00783
Mailing Address - Country:UM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28-20 AVE. GILBERTO
Practice Address - Street 2:URB. SIERRA BAYAMON
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961
Practice Address - Country:US
Practice Address - Phone:787-786-9610
Practice Address - Fax:787-786-9610
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR006538183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR132457OtherREGISTRO