Healthcare Provider Details

I. General information

NPI: 1003658311
Provider Name (Legal Business Name): JASON FOLEY GILBERT LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JASON FOLEY CAPRIO

II. Dates (important events)

Enumeration Date: 06/07/2024
Last Update Date: 06/07/2024
Certification Date: 06/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 HAINES AVE NW
ALBUQUERQUE NM
87102-1226
US

IV. Provider business mailing address

21 RANCH RD
CEDAR CREST NM
87008-9712
US

V. Phone/Fax

Practice location:
  • Phone: 505-268-5611
  • Fax:
Mailing address:
  • Phone: 505-681-0499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2024-0411
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: