Healthcare Provider Details

I. General information

NPI: 1427843440
Provider Name (Legal Business Name): MARY JESSICA RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2025
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 LOPEZ RD
LAS CRUCES NM
88007-6806
US

IV. Provider business mailing address

PO BOX 2131
MESILLA PARK NM
88047-2131
US

V. Phone/Fax

Practice location:
  • Phone: 575-499-9548
  • Fax:
Mailing address:
  • Phone: 575-499-9548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number124148987
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: