Basic Information
Provider Information | |||||||||
NPI: | 1639740608 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: | LAURA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2807 CARRETAS CT | ||||||||
Address2: |   | ||||||||
City: | LAS CRUCES | ||||||||
State: | NM | ||||||||
PostalCode: | 880071912 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5755511757 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2351 25TH ST UNIT B | ||||||||
Address2: |   | ||||||||
City: | ALAMOGORDO | ||||||||
State: | NM | ||||||||
PostalCode: | 883108722 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5754465321 | ||||||||
FaxNumber: | 5754465309 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2021 | ||||||||
LastUpdateDate: | 07/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/07/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | M-11487 | NM | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
No ID Information.