Healthcare Provider Details

I. General information

NPI: 1376092981
Provider Name (Legal Business Name): JESSICA SOUCY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA OSBORNE

II. Dates (important events)

Enumeration Date: 09/23/2016
Last Update Date: 11/12/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3080 BRELAND DR
LAS CRUCES NM
88003
US

IV. Provider business mailing address

P.O. BOX 30001 MSC 3529
LAS CRUCES NM
88003-8001
US

V. Phone/Fax

Practice location:
  • Phone: 575-646-1512
  • Fax: 575-646-6428
Mailing address:
  • Phone: 575-646-1512
  • Fax: 575-646-6428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-02977
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: