=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225520620
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENCY CYNTHIA SACHIDANANDAM MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2018
-----------------------------------------------------
Last Update Date | 11/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 N MESA ST
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79902-3976
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-215-6170
-----------------------------------------------------
Fax | 915-215-8659
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5130 GATEWAY BLVD E # 51015
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79905-1608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-215-4480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 333027
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | MD2024-0060
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | V0144
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | V0144
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------