=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659645901
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA SIMONE VENTURA-EWING LPCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2012
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2504 CAMINO ENTRADA
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87507-4851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-471-5006
-----------------------------------------------------
Fax | 505-820-9220
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2504 CAMINO ENTRADA
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87507-4851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-471-5006
-----------------------------------------------------
Fax | 505-820-9220
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 0188221
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 0155611
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------