Healthcare Provider Details

I. General information

NPI: 1063937498
Provider Name (Legal Business Name): JEREMIAH ACOSTA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2017
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 ALTEZ ST NE APT 3
ALBUQUERQUE NM
87123-2657
US

IV. Provider business mailing address

137 ALTEZ ST NE APT 3
ALBUQUERQUE NM
87123-2657
US

V. Phone/Fax

Practice location:
  • Phone: 575-200-7566
  • Fax:
Mailing address:
  • Phone: 575-200-7566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2023-0348
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: