Healthcare Provider Details

I. General information

NPI: 1649923111
Provider Name (Legal Business Name): JESSICA MAYA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2022
Last Update Date: 02/03/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 FERNANDEZ RD
LOS LUNAS NM
87031-8703
US

IV. Provider business mailing address

2200 GUN CLUB RD SW
ALBUQUERQUE NM
87105-6415
US

V. Phone/Fax

Practice location:
  • Phone: 505-508-0865
  • Fax:
Mailing address:
  • Phone: 505-508-0865
  • Fax: 855-764-7379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: