Healthcare Provider Details

I. General information

NPI: 1114844081
Provider Name (Legal Business Name): CISCO JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1742 MCRAE AVE
LAS CRUCES NM
88001-2546
US

IV. Provider business mailing address

720 HARLACKER RD
LA MESA NM
88044-9305
US

V. Phone/Fax

Practice location:
  • Phone: 575-650-3997
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: