Provider Demographics
NPI:1932837754
Name:SANTIAGO DE JESUS, JUAN CARLOS JR (MD)
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:CARLOS
Last Name:SANTIAGO DE JESUS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. SANTA CLARA, CALLE RESPLANDECIENTE
Mailing Address - Street 2:186
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00716
Mailing Address - Country:US
Mailing Address - Phone:787-677-0141
Mailing Address - Fax:
Practice Address - Street 1:CTIAM, 500 PR-5
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961
Practice Address - Country:US
Practice Address - Phone:787-677-0141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-10
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4696101YA0400X
PR299040101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1932837754Medicaid