Healthcare Provider Details

I. General information

NPI: 1689585481
Provider Name (Legal Business Name): LENAH E JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 9TH ST
ALAMOGORDO NM
88310-6416
US

IV. Provider business mailing address

816 9TH ST
ALAMOGORDO NM
88310-6416
US

V. Phone/Fax

Practice location:
  • Phone: 575-285-9265
  • Fax: 575-286-1948
Mailing address:
  • Phone: 575-285-9265
  • Fax: 575-286-1948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB1623967
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: