Provider Demographics
NPI:1760243950
Name:DANIELLE, JESS DARIELLE
Entity Type:Individual
Prefix:
First Name:JESS
Middle Name:DARIELLE
Last Name:DANIELLE
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 1:410 STANFORD DR SE APT A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-3682
Mailing Address - Country:US
Mailing Address - Phone:970-779-0442
Mailing Address - Fax:
Practice Address - Street 1:2601 WYOMING BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-1035
Practice Address - Country:US
Practice Address - Phone:505-503-0272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health