Healthcare Provider Details

I. General information

NPI: 1043122724
Provider Name (Legal Business Name): JESUS GRIJALVA LSAA, CPSW, CPFS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 MISSION AVE.
FARMINGTON NM
87401
US

IV. Provider business mailing address

400 N LIGHT PLANT RD TRLR 5
AZTEC NM
87410-1547
US

V. Phone/Fax

Practice location:
  • Phone: 505-325-7218
  • Fax:
Mailing address:
  • Phone: 505-608-5365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2026-0683
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: