Provider Demographics
NPI:1902578974
Name:AVILA, JAILEENE
Entity Type:Individual
Prefix:
First Name:JAILEENE
Middle Name:
Last Name:AVILA
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:CONDOMINIO MUNDO FELIZ APT. #105
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00979
Mailing Address - Country:US
Mailing Address - Phone:787-379-6123
Mailing Address - Fax:
Practice Address - Street 1:CONDOMINIO MUNDO FELIZ APT. #105
Practice Address - Street 2:
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00979
Practice Address - Country:US
Practice Address - Phone:787-379-6123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6176103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist