Healthcare Provider Details

I. General information

NPI: 1649555970
Provider Name (Legal Business Name): JD BEHAVIORAL SUPPORTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2011
Last Update Date: 10/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 PASEO VISTA LOOP NE
RIO RANCHO NM
87124-4549
US

IV. Provider business mailing address

425 PASEO VISTA LOOP NE
RIO RANCHO NM
87124-4549
US

V. Phone/Fax

Practice location:
  • Phone: 505-259-2802
  • Fax: 505-892-2380
Mailing address:
  • Phone: 505-259-2802
  • Fax: 505-892-2380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberX-07553
License Number StateNM

VIII. Authorized Official

Name: JEANNE E DUGGINS
Title or Position: DIRECTOR
Credential: LISW
Phone: 505-259-2802