Provider Demographics
NPI:1831255892
Name:MEDINA, JUAN DE JESUS (PHD)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:DE JESUS
Last Name:MEDINA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9550 COTTO STATION
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00613
Mailing Address - Country:US
Mailing Address - Phone:787-878-3552
Mailing Address - Fax:787-879-8633
Practice Address - Street 1:2DO PISO CARR 129
Practice Address - Street 2:ANTIGUO HOSPITAL DE DISTRITO
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612
Practice Address - Country:US
Practice Address - Phone:787-878-3552
Practice Address - Fax:787-879-8633
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR453103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical