Healthcare Provider Details

I. General information

NPI: 1306059522
Provider Name (Legal Business Name): JESSE S MARTINEZ LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JESSE S MARTINEZ LISW

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

577 EL LLANO RD
ESPANOLA NM
87532-2911
US

IV. Provider business mailing address

577 EL LLANO RD
ESPANOLA NM
87532-2911
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-1656
  • Fax:
Mailing address:
  • Phone: 505-753-1656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI-3701
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: