Healthcare Provider Details

I. General information

NPI: 1215778634
Provider Name (Legal Business Name): JACQUELINE AVITIA-JAQUEZ LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 OSUNA RD NE STE 102
ALBUQUERQUE NM
87109-2587
US

IV. Provider business mailing address

5801 OSUNA RD NE STE 102
ALBUQUERQUE NM
87109-2587
US

V. Phone/Fax

Practice location:
  • Phone: 505-639-4769
  • Fax:
Mailing address:
  • Phone: 505-639-4769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number20240853
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: