Provider Demographics
NPI:1891212882
Name:SPOHN, JESSICA (LCSW, LADAC, CHES)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SPOHN
Suffix:
Gender:F
Credentials:LCSW, LADAC, CHES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 CAMINO ENTRADA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-4851
Mailing Address - Country:US
Mailing Address - Phone:575-323-9425
Mailing Address - Fax:
Practice Address - Street 1:2028 E AZTEC AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-4804
Practice Address - Country:US
Practice Address - Phone:888-244-3940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCAD0224842101YA0400X
NM25076174H00000X
NMC-113301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM45086231Medicaid