Healthcare Provider Details

I. General information

NPI: 1063178440
Provider Name (Legal Business Name): JAY BLACKWELL MA, CPSW, LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 CARLISLE BLVD NE STE 105
ALBUQUERQUE NM
87110-1680
US

IV. Provider business mailing address

3150 CARLISLE BLVD NE STE 105
ALBUQUERQUE NM
87110-1680
US

V. Phone/Fax

Practice location:
  • Phone: 505-652-4659
  • Fax:
Mailing address:
  • Phone: 56-524-6595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTL0223091
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1241
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: