Provider Demographics
NPI:1104422302
Name:BENAVIDEZ, JESSICA (LMSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BENAVIDEZ
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:MONTANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-0158
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:
Practice Address - Street 1:1235 8TH ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4219
Practice Address - Country:US
Practice Address - Phone:505-425-6788
Practice Address - Fax:505-747-7396
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
M-11870104100000X
NMX-11743101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health