Healthcare Provider Details

I. General information

NPI: 1861114456
Provider Name (Legal Business Name): CASSANDRA FAITH JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 BARBARA LOOP SE
RIO RANCHO NM
87124-1000
US

IV. Provider business mailing address

4916 HAYWORTH HILLS DR NE
RIO RANCHO NM
87144-8667
US

V. Phone/Fax

Practice location:
  • Phone: 505-702-8547
  • Fax:
Mailing address:
  • Phone: 505-339-7360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1460
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: