Provider Demographics
NPI:1063295129
Name:GUZMAN, JESSELLE D
Entity type:Individual
Prefix:
First Name:JESSELLE
Middle Name:D
Last Name:GUZMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 APPALOOSA DR STE C310
Mailing Address - Street 2:
Mailing Address - City:SUNLAND PARK
Mailing Address - State:NM
Mailing Address - Zip Code:88063-8904
Mailing Address - Country:US
Mailing Address - Phone:915-408-5908
Mailing Address - Fax:
Practice Address - Street 1:1580 APPALOOSA DR STE C310
Practice Address - Street 2:
Practice Address - City:SUNLAND PARK
Practice Address - State:NM
Practice Address - Zip Code:88063-8904
Practice Address - Country:US
Practice Address - Phone:575-332-9086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM104100000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No104100000XBehavioral Health & Social Service ProvidersSocial Worker