Healthcare Provider Details

I. General information

NPI: 1982202131
Provider Name (Legal Business Name): JASON SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2020
Last Update Date: 10/10/2020
Certification Date: 10/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 E IDAHO AVE STE 2B
LAS CRUCES NM
88001-4701
US

IV. Provider business mailing address

715 E IDAHO AVE STE 2B
LAS CRUCES NM
88001-4701
US

V. Phone/Fax

Practice location:
  • Phone: 575-556-9585
  • Fax:
Mailing address:
  • Phone: 575-556-9585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: