Provider Demographics
NPI:1265781157
Name:VIARREAL, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:VIARREAL
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 28220
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87592
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:541 QUANTUM ROAD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124
Practice Address - Country:US
Practice Address - Phone:505-994-9178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
NMM-08089104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor