Healthcare Provider Details

I. General information

NPI: 1124231618
Provider Name (Legal Business Name): JACKIE LYNNE WEST LPCC, LADAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 GIBSON BLVD SE
ALBUQUERQUE NM
87108-5566
US

IV. Provider business mailing address

2504 CAMINO ENTRADA
SANTA FE NM
87507-4851
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-8978
  • Fax: 505-841-8977
Mailing address:
  • Phone: 505-216-2727
  • Fax: 505-365-1006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4749
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0098501
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCTB-2022-0948
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: