Healthcare Provider Details

I. General information

NPI: 1396673141
Provider Name (Legal Business Name): JACOB DAMIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

648 N ALAMEDA BLVD
LAS CRUCES NM
88005-2131
US

IV. Provider business mailing address

757 VILLA ANTIGUA CT
EL PASO TX
79932-4208
US

V. Phone/Fax

Practice location:
  • Phone: 575-521-0022
  • Fax:
Mailing address:
  • Phone: 915-996-3617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC-2026-0016
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: