1609102227 NPI number — JESSICA L SPINNER LISW

Table of content: JESSICA L SPINNER LISW (NPI 1609102227)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609102227 NPI number — JESSICA L SPINNER LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPINNER
Provider First Name:
JESSICA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LISW
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:
1609102227
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1319
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHIPROCK
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87420-1319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-598-5881
Provider Business Mailing Address Fax Number:
505-598-9712

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 COUNTY ROAD 6100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KIRTLAND
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87417-9317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-598-5881
Provider Business Practice Location Address Fax Number:
505-598-9712
Provider Enumeration Date:
11/02/2009

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: 1041S0200X , with the licence number:  356980 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: I-08455 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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