Healthcare Provider Details

I. General information

NPI: 1982122248
Provider Name (Legal Business Name): JACKIE ANNE MORENO LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2017
Last Update Date: 09/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W HEMLOCK ST
DEMING NM
88030-3622
US

IV. Provider business mailing address

2605 S GOLD AVE
DEMING NM
88030-6507
US

V. Phone/Fax

Practice location:
  • Phone: 575-545-2459
  • Fax:
Mailing address:
  • Phone: 575-545-8171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-09535
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: