Provider Demographics
NPI:1558715003
Name:SIMMON, JESSIE MAE (MD)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:MAE
Last Name:SIMMON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 INDIAN SCHOOL RD NE STE 110
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3991
Mailing Address - Country:US
Mailing Address - Phone:989-619-7316
Mailing Address - Fax:
Practice Address - Street 1:4705 MONTGOMERY BLVD NE STE 301
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1234
Practice Address - Country:US
Practice Address - Phone:505-727-4500
Practice Address - Fax:505-727-4505
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-21
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMMD2020-0647207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMMD2020-0647OtherLICENSE #