Healthcare Provider Details

I. General information

NPI: 1053231043
Provider Name (Legal Business Name): JESSA MARIE VILLOSAN NOVICIO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 COMMERCE DR STE C
LAS CRUCES NM
88011-8248
US

IV. Provider business mailing address

1115 COMMERCE DR STE C
LAS CRUCES NM
88011-8248
US

V. Phone/Fax

Practice location:
  • Phone: 575-525-2450
  • Fax:
Mailing address:
  • Phone: 575-525-2450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number052170
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-2026-0204
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: