Provider Demographics
NPI:1982159653
Name:GOLDTOOTH, JESSICA (PSR INSTRUCTOR)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GOLDTOOTH
Suffix:
Gender:F
Credentials:PSR INSTRUCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 UNSER BLVD NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-4045
Mailing Address - Country:US
Mailing Address - Phone:505-896-0928
Mailing Address - Fax:
Practice Address - Street 1:184 UNSER BLVD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4045
Practice Address - Country:US
Practice Address - Phone:505-896-0928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst