Basic Information
| Provider Information | |||||||||
| NPI: | 1336646645 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRUJILLO | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 MARBLE AVE NE BLDG 2 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722190 | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 S CAMINO DEL PUEBLO | ||||||||
| Address2: | |||||||||
| City: | BERNALILLO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870046276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058672383 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2018 | ||||||||
| LastUpdateDate: | 01/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 104100000X | M-11094 | NM | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 390200000X | 05 | NM | MEDICAID |