MEDICARE: MS. JESSICA JIM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247200000X	Other Technician	PM000110	NM

General Provider Information

NPI Number	:	1235660143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JESSICA JIM

Provider Business Mailing Address
First Line	:	920 N ALAMEDA BLVD
Second Line	:	STE 2
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-2291
Country	:	US
Telephone Number	:	575-636-8406
Fax Number	:

Provider Business Practice Location Address
First Line	:	920 N ALAMEDA BLVD
Second Line	:	STE 2
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-2291
Country	:	US
Telephone Number	:	575-636-8406
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2017
Last Update Date	:	03/22/2017

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