Provider Demographics
NPI:1679233902
Name:MIRANDA, JESNY LICETH
Entity type:Individual
Prefix:
First Name:JESNY
Middle Name:LICETH
Last Name:MIRANDA
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 1:14708 HARRY FLOURNOY AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79938-1030
Mailing Address - Country:US
Mailing Address - Phone:915-346-9100
Mailing Address - Fax:
Practice Address - Street 1:1390 GEORGE DIETER DR STE 140
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-7430
Practice Address - Country:US
Practice Address - Phone:915-320-1390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104143104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker