Provider Demographics
NPI:1851819627
Name:TOMS, JESEE DANIELLE
Entity Type:Individual
Prefix:
First Name:JESEE
Middle Name:DANIELLE
Last Name:TOMS
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:PO BOX 505
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:NM
Mailing Address - Zip Code:88065-0505
Mailing Address - Country:US
Mailing Address - Phone:575-654-6034
Mailing Address - Fax:
Practice Address - Street 1:221 BORNITE
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:NM
Practice Address - Zip Code:88065
Practice Address - Country:US
Practice Address - Phone:575-654-6034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician