Healthcare Provider Details

I. General information

NPI: 1316856271
Provider Name (Legal Business Name): JESSICA RAE VAN WORMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2669 SCENIC DR
ALAMOGORDO NM
88310-8700
US

IV. Provider business mailing address

772 CHOLLA DR
ALAMOGORDO NM
88310-7780
US

V. Phone/Fax

Practice location:
  • Phone: 575-439-6100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number91624
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: