Healthcare Provider Details

I. General information

NPI: 1962018697
Provider Name (Legal Business Name): JERRY WOODLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2020
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 BROADWAY BLVD SE
ALBUQUERQUE NM
87102-4285
US

IV. Provider business mailing address

819 FORRESTER NE APT B
ALBUQUERQUE NM
87102
US

V. Phone/Fax

Practice location:
  • Phone: 505-394-8412
  • Fax:
Mailing address:
  • Phone: 505-394-8412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: