Healthcare Provider Details

I. General information

NPI: 1871408567
Provider Name (Legal Business Name): CHELSEA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 LOMA GRANDE RD
NOGAL NM
88341-9503
US

IV. Provider business mailing address

120 LOMA GRANDE RD
NOGAL NM
88341-9503
US

V. Phone/Fax

Practice location:
  • Phone: 575-315-4941
  • Fax:
Mailing address:
  • Phone: 575-315-4941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2026-0685
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: