Healthcare Provider Details

I. General information

NPI: 1821110735
Provider Name (Legal Business Name): JACK ESTES MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 02/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 MORNINGSIDE DR. NE
ALBUQUERQUE NM
87190
US

IV. Provider business mailing address

PO BOX 30103
ALBUQUERQUE NM
87190-0103
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-4191
  • Fax:
Mailing address:
  • Phone: 505-255-4191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCC3280
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: