Provider Demographics
NPI:1154019149
Name:CARABALLO RIVERA, JACKELINE
Entity type:Individual
Prefix:
First Name:JACKELINE
Middle Name:
Last Name:CARABALLO RIVERA
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:URB COCOBEACH 210 CALLE MANATI
Mailing Address - Street 2:CALLE MANATI
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745
Mailing Address - Country:US
Mailing Address - Phone:787-516-6607
Mailing Address - Fax:
Practice Address - Street 1:URB COCOBEACH 210
Practice Address - Street 2:CALLE MANATI
Practice Address - City:RIO GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00745
Practice Address - Country:US
Practice Address - Phone:787-516-6607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI6187103TC1900X
PR6187103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling