Provider Demographics
NPI:1770092785
Name:RUIZ MARIN, JEARLEAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:JEARLEAN
Middle Name:
Last Name:RUIZ MARIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3425 S RAVELLO DR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3486
Mailing Address - Country:US
Mailing Address - Phone:939-717-2705
Mailing Address - Fax:
Practice Address - Street 1:2155 OLD MOULTRIE RD STE 101
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5106
Practice Address - Country:US
Practice Address - Phone:863-709-8110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9939103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical