Healthcare Provider Details

I. General information

NPI: 1043376288
Provider Name (Legal Business Name): JACK L. HUMPHRIES, LISW, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8800 PALOMAR AVE NE
ALBUQUERQUE NM
87109-7205
US

IV. Provider business mailing address

PO BOX 16387
ALBUQUERQUE NM
87191-6387
US

V. Phone/Fax

Practice location:
  • Phone: 505-620-5225
  • Fax: 505-798-1743
Mailing address:
  • Phone: 505-620-5225
  • Fax: 505-798-1743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-3613
License Number StateNM

VIII. Authorized Official

Name: MR. JACK L. HUMPHRIES
Title or Position: PRESIDENT
Credential: LISW
Phone: 505-620-5225