Healthcare Provider Details

I. General information

NPI: 1255757704
Provider Name (Legal Business Name): JACQUELINE GRAJEDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2014
Last Update Date: 05/25/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ALL FAITHS CHILDREN'S ADVOCACY CENTER 8401 CONSTITUTION AVE NE
ALBUQUERQUE NM
87110
US

IV. Provider business mailing address

2600 SOL DE VIDA NW
ALBUQUERQUE NM
87120-1396
US

V. Phone/Fax

Practice location:
  • Phone: 505-271-0329
  • Fax:
Mailing address:
  • Phone: 505-730-6726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0201601
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberT-0177061
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: