Provider Demographics
NPI:1154975688
Name:ALMODOVAR MEDINA, JAIRA MARIE
Entity type:Individual
Prefix:
First Name:JAIRA
Middle Name:MARIE
Last Name:ALMODOVAR MEDINA
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 1:29 CALLE CAOBA
Mailing Address - Street 2:
Mailing Address - City:SANTA ISABEL
Mailing Address - State:PR
Mailing Address - Zip Code:00757-3223
Mailing Address - Country:US
Mailing Address - Phone:787-702-1074
Mailing Address - Fax:
Practice Address - Street 1:PLAZA CAYEY MONTELLANO
Practice Address - Street 2:
Practice Address - City:CAYEY
Practice Address - State:PR
Practice Address - Zip Code:00736
Practice Address - Country:US
Practice Address - Phone:787-520-7157
Practice Address - Fax:787-520-7164
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR240151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical