Provider Demographics
NPI:1790143519
Name:RISINGER, JESSICA (LSAA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:RISINGER
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 VANCOUVER RD SE APT B
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-3855
Mailing Address - Country:US
Mailing Address - Phone:505-301-2735
Mailing Address - Fax:
Practice Address - Street 1:557 VANCOUVER RD SE APT B
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-3855
Practice Address - Country:US
Practice Address - Phone:505-301-2735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0156941101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)