Healthcare Provider Details

I. General information

NPI: 1104817303
Provider Name (Legal Business Name): GAIL E JACKSON LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 TRUMAN ST NE
ALBUQUERQUE NM
87110-6443
US

IV. Provider business mailing address

1108 CALLE DEL RANCHERO NE
ALBUQUERQUE NM
87106-1906
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-6916
  • Fax:
Mailing address:
  • Phone: 505-256-4742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberI-0090
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: