Provider Demographics
NPI:1205997491
Name:GARCIA-PRADA, JESUS G (PHD)
Entity type:Individual
Prefix:DR
First Name:JESUS
Middle Name:G
Last Name:GARCIA-PRADA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12441 TOWNER AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-3659
Mailing Address - Country:US
Mailing Address - Phone:505-294-8060
Mailing Address - Fax:
Practice Address - Street 1:5100 SECOND STREET NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4009
Practice Address - Country:US
Practice Address - Phone:505-342-3799
Practice Address - Fax:505-342-3785
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2632101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM101546OtherVALUE OPTIONS
NM92433286Medicaid