Provider Demographics
NPI:1245553379
Name:MORENO, JESSICA NICOLE (LISW)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:NICOLE
Last Name:MORENO
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 S SOLANO DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-3758
Mailing Address - Country:US
Mailing Address - Phone:575-522-4004
Mailing Address - Fax:575-522-9017
Practice Address - Street 1:1320 S SOLANO DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3758
Practice Address - Country:US
Practice Address - Phone:575-522-4004
Practice Address - Fax:575-522-9017
Is Sole Proprietor?:No
Enumeration Date:2010-03-03
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-077611041C0700X
NMM-07157104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker