Healthcare Provider Details

I. General information

NPI: 1861050320
Provider Name (Legal Business Name): JEWELL CODY LADAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 02/11/2026
Certification Date: 02/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 GAIL HARRIS ST
ROSWELL NM
88203-8116
US

IV. Provider business mailing address

28 W MARTIN ST
ROSWELL NM
88203-8451
US

V. Phone/Fax

Practice location:
  • Phone: 575-347-3400
  • Fax:
Mailing address:
  • Phone: 907-416-8571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2025-0376
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: