Provider Demographics
NPI:1114391273
Name:BRASWELL, JESSICA I
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BRASWELL
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 US-60
Mailing Address - Street 2:
Mailing Address - City:SOORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801
Mailing Address - Country:US
Mailing Address - Phone:575-835-2444
Mailing Address - Fax:
Practice Address - Street 1:1200 US-60
Practice Address - Street 2:
Practice Address - City:SOORRO
Practice Address - State:NM
Practice Address - Zip Code:87801
Practice Address - Country:US
Practice Address - Phone:575-835-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-30
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0171871101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)