Healthcare Provider Details

I. General information

NPI: 1760347884
Provider Name (Legal Business Name): JACQUELINE CHAVEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5101 COPPER AVE NE
ALBUQUERQUE NM
87108-5352
US

IV. Provider business mailing address

211 18TH ST SE
RIO RANCHO NM
87124-2666
US

V. Phone/Fax

Practice location:
  • Phone: 505-706-0865
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: