Healthcare Provider Details

I. General information

NPI: 1043497175
Provider Name (Legal Business Name): JESSI PRISCILLA CROSS LPAT ATR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 04/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 OLD SANTA FE TRL STE 12
SANTA FE NM
87505-1300
US

IV. Provider business mailing address

PO BOX 32394
SANTA FE NM
87594-2394
US

V. Phone/Fax

Practice location:
  • Phone: 505-316-1845
  • Fax:
Mailing address:
  • Phone: 505-316-1845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0134691
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: