Healthcare Provider Details

I. General information

NPI: 1164197612
Provider Name (Legal Business Name): JESSICA KINSEY LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2021
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 ANGELINA BLVD
CHAPARRAL NM
88081-7558
US

IV. Provider business mailing address

204 ANGELINA BLVD
CHAPARRAL NM
88081-7558
US

V. Phone/Fax

Practice location:
  • Phone: 575-824-8100
  • Fax:
Mailing address:
  • Phone: 575-824-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberX11935
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: