Healthcare Provider Details

I. General information

NPI: 1578293544
Provider Name (Legal Business Name): JESSICA M. FETT PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

1422 RIVER ROCK PL APT 304
MEMPHIS TN
38103-6989
US

V. Phone/Fax

Practice location:
  • Phone: 505-767-6001
  • Fax:
Mailing address:
  • Phone: 515-490-6080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3821
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: