Provider Demographics
NPI:1841505138
Name:SUNDRAM, JESSICA AYESHA RODRIGUES
Entity type:Individual
Prefix:MS
First Name:JESSICA AYESHA
Middle Name:RODRIGUES
Last Name:SUNDRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:RODRIGUES
Other - Last Name:SUNDRAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:300 MENAUL BLVD NW STE A PMB 468
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-9951
Mailing Address - Country:US
Mailing Address - Phone:505-750-3605
Mailing Address - Fax:505-340-3941
Practice Address - Street 1:200 ROSEMONT AVE NE APT C
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1599
Practice Address - Country:US
Practice Address - Phone:505-750-3605
Practice Address - Fax:505-340-3941
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-11
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-090201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM40657043Medicaid