1558715003 NPI number — JESSIE MAE SIMMON MD

Table of content: JESSIE MAE SIMMON MD (NPI 1558715003)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558715003 NPI number — JESSIE MAE SIMMON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIMMON
Provider First Name:
JESSIE
Provider Middle Name:
MAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558715003
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 26666
Provider Second Line Business Mailing Address:
PHS PROVIDER ENROLLMENT
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87125-6666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 CENTRAL AVENUE SE SUITE 5600
Provider Second Line Business Practice Location Address:
OBGYN HOSPITALIST
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87106-4920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-841-0922
Provider Business Practice Location Address Fax Number:
505-563-6380
Provider Enumeration Date:
04/21/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  MD2020-0647 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MD2020-0647 . This is a "LICENSE #" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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