Healthcare Provider Details

I. General information

NPI: 1902506512
Provider Name (Legal Business Name): JESSICA RUIZ BALDERRAMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2023
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 4TH ST
LUBBOCK TX
79430-5055
US

IV. Provider business mailing address

7601 AKRON AVE UNIT A
LUBBOCK TX
79423-2170
US

V. Phone/Fax

Practice location:
  • Phone: 806-743-7335
  • Fax: 806-743-7329
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1001745
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: