Healthcare Provider Details

I. General information

NPI: 1629908579
Provider Name (Legal Business Name): TRINIDAD AVALOS JASSO JR. RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 S MAIN ST STE 7000A
LAS CRUCES NM
88001-1207
US

IV. Provider business mailing address

PO BOX 153
DONA ANA NM
88032-0153
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-0289
  • Fax:
Mailing address:
  • Phone: 575-522-0289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberR20927
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: