Healthcare Provider Details

I. General information

NPI: 1104137843
Provider Name (Legal Business Name): JODI RENEE CHESTNUT-GUTIERREZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2010
Last Update Date: 06/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 ZARAGOSA B-4
EL PASO TX
79936-7905
US

IV. Provider business mailing address

1514 N ZARAGOSA B-4
EL PASO TX
79936-7905
US

V. Phone/Fax

Practice location:
  • Phone: 915-544-3500
  • Fax: 915-855-4404
Mailing address:
  • Phone: 915-544-3500
  • Fax: 915-855-4404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number31999
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: