Provider Demographics
NPI:1356631667
Name:MALDONADO, JESSICA (ASL)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:ASL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4442
Mailing Address - Country:US
Mailing Address - Phone:575-763-9517
Mailing Address - Fax:575-742-2369
Practice Address - Street 1:810 E 21ST ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4442
Practice Address - Country:US
Practice Address - Phone:575-763-9517
Practice Address - Fax:575-742-2369
Is Sole Proprietor?:No
Enumeration Date:2011-04-08
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4890235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM40509257Medicaid