Provider Demographics
NPI:1497499677
Name:GONG, JESSICA MICHELLE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MICHELLE
Last Name:GONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSE
Other - Middle Name:
Other - Last Name:WEST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1601 PENNSYLVANIA ST NE UNIT I9
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5500
Mailing Address - Country:US
Mailing Address - Phone:505-449-8782
Mailing Address - Fax:
Practice Address - Street 1:1601 PENNSYLVANIA ST NE UNIT I9
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5500
Practice Address - Country:US
Practice Address - Phone:505-449-8782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician