Provider Demographics
NPI:1053988410
Name:RIVAS, JADE
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:RIVAS
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:CR 141 1617C PRIVATE DR 13
Mailing Address - Street 2:
Mailing Address - City:MEDANALES
Mailing Address - State:NM
Mailing Address - Zip Code:87548
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CR 141 1617C PRIVATE DR 13
Practice Address - Street 2:
Practice Address - City:MEDANALES
Practice Address - State:NM
Practice Address - Zip Code:87548
Practice Address - Country:US
Practice Address - Phone:505-901-0582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician