Healthcare Provider Details

I. General information

NPI: 1174241541
Provider Name (Legal Business Name): JESSICA TUMPOSKY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 08/22/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 N WEST ST
SILVER CITY NM
88061-4635
US

IV. Provider business mailing address

1701 N JUNIPER AVE
SILVER CITY NM
88061-5675
US

V. Phone/Fax

Practice location:
  • Phone: 575-654-0576
  • Fax:
Mailing address:
  • Phone: 575-313-5574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2022-0284
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: