Provider Demographics
NPI:1871227249
Name:RUELAS, JESUS JAVIER I (CPSW)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:JAVIER
Last Name:RUELAS
Suffix:I
Gender:M
Credentials:CPSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5312 JAGUAR DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-1827
Mailing Address - Country:US
Mailing Address - Phone:505-471-4985
Mailing Address - Fax:
Practice Address - Street 1:1600 SAINT MICHAELS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7615
Practice Address - Country:US
Practice Address - Phone:505-471-4985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1171405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional