Provider Demographics
NPI:1518536176
Name:HERNANDEZ, JESSE E (CPSW)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:E
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:CPSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 CONDERSHIRE DR SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-5253
Mailing Address - Country:US
Mailing Address - Phone:505-877-3644
Mailing Address - Fax:
Practice Address - Street 1:3701 CONDERSHIRE DR SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121-5253
Practice Address - Country:US
Practice Address - Phone:505-877-3644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1097175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty