Healthcare Provider Details

I. General information

NPI: 1841690732
Provider Name (Legal Business Name): ERICA JACKNIN MA, ATR-BC, LPAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2014
Last Update Date: 01/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SHERLOCK CT
CORRALES NM
87048
US

IV. Provider business mailing address

100 SHERLOCK CT
CORRALES NM
87048-6915
US

V. Phone/Fax

Practice location:
  • Phone: 303-929-5307
  • Fax:
Mailing address:
  • Phone: 303-929-5307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License NumberCAT0201081
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: