Healthcare Provider Details

I. General information

NPI: 1558222497
Provider Name (Legal Business Name): AMANDA MARIE JACQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2025
Last Update Date: 11/20/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 CURIE DR STE C
EL PASO TX
79902-2920
US

IV. Provider business mailing address

2930 N STANTON ST
EL PASO TX
79902-2511
US

V. Phone/Fax

Practice location:
  • Phone: 915-577-7951
  • Fax: 915-577-7952
Mailing address:
  • Phone: 915-351-0523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1213030
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: