1508274986 NPI number — JENNIFER ALFONSO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508274986 NPI number — JENNIFER ALFONSO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALFONSO
Provider First Name:
JENNIFER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508274986
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
URB. ALTRAS DEL RIO CALLE 5 A11
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAYAMON
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-914-1130
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
D6 CLL EBANO
Provider Second Line Business Practice Location Address:
COND PARQUE DE SAN PATRICIO
Provider Business Practice Location Address City Name:
GUAYNABO
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00968
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-914-1130
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/29/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC1900X , with the licence number: 006316 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1307576 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1303295 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: M18463 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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