Healthcare Provider Details

I. General information

NPI: 1265685358
Provider Name (Legal Business Name): JESSE PARRISH ED.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2008
Last Update Date: 11/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 LASER DR NE
RIO RANCHO NM
87124-4517
US

IV. Provider business mailing address

500 LASER DR NE
RIO RANCHO NM
87124-4517
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-0667
  • Fax: 505-994-4609
Mailing address:
  • Phone: 505-896-0667
  • Fax: 505-994-4609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number300023
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: