Healthcare Provider Details

I. General information

NPI: 1972259208
Provider Name (Legal Business Name): JESSICA DICKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2022
Last Update Date: 02/24/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3908 JUAN TABO BLVD NE
ALBUQUERQUE NM
87111-3971
US

IV. Provider business mailing address

3908 JUAN TABO BLVD NE
ALBUQUERQUE NM
87111-3971
US

V. Phone/Fax

Practice location:
  • Phone: 505-363-1428
  • Fax:
Mailing address:
  • Phone: 505-363-1428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberDOM1283
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: