Basic Information
| Provider Information | |||||||||
| NPI: | 1265781157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VIARREAL | ||||||||
| FirstName: | JESSICA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 28220 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87592 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 541 QUANTUM ROAD NE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059949178 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2012 | ||||||||
| LastUpdateDate: | 09/19/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 104100000X | M-08089 | NM | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.