Healthcare Provider Details

I. General information

NPI: 1265275572
Provider Name (Legal Business Name): JORDAN MARIE WEATHERLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2435 S TELSHOR BLVD
LAS CRUCES NM
88011-5029
US

IV. Provider business mailing address

PO BOX 405
SAN MIGUEL NM
88058-0405
US

V. Phone/Fax

Practice location:
  • Phone: 575-323-1315
  • Fax: 833-524-5203
Mailing address:
  • Phone: 575-323-1315
  • Fax: 833-524-5203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCTB-2025-0423
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: