Healthcare Provider Details

I. General information

NPI: 1245553379
Provider Name (Legal Business Name): JESSICA NICOLE MORENO LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2010
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 S SOLANO DR
LAS CRUCES NM
88001-3758
US

IV. Provider business mailing address

1320 S SOLANO DR
LAS CRUCES NM
88001-3758
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-4004
  • Fax: 575-522-9017
Mailing address:
  • Phone: 575-522-4004
  • Fax: 575-522-9017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-07761
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-07157
License Number StateNM

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: