Provider Demographics
NPI:1659952232
Name:SPOONER, JESSICA TEAL
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:TEAL
Last Name:SPOONER
Suffix:
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 1:1805 CARLISLE BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-4905
Mailing Address - Country:US
Mailing Address - Phone:505-720-9949
Mailing Address - Fax:
Practice Address - Street 1:1805 CARLISLE BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4905
Practice Address - Country:US
Practice Address - Phone:505-842-9911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-114881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical