Provider Demographics
NPI:1720739899
Name:MATOS RENTA, JELISSE (PSYD)
Entity type:Individual
Prefix:DR
First Name:JELISSE
Middle Name:
Last Name:MATOS RENTA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JELISSE
Other - Middle Name:
Other - Last Name:MATOS RENTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED
Mailing Address - Street 1:202 CALLE PRINCIPE
Mailing Address - Street 2:
Mailing Address - City:COTO LAUREL
Mailing Address - State:PR
Mailing Address - Zip Code:00780-3211
Mailing Address - Country:US
Mailing Address - Phone:787-905-5216
Mailing Address - Fax:
Practice Address - Street 1:CALLE MAYOR
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00730
Practice Address - Country:US
Practice Address - Phone:787-905-5216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6671103TC2200X, 103TS0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR131920Medicaid