Healthcare Provider Details

I. General information

NPI: 1124345681
Provider Name (Legal Business Name): JACQUELINE Y BEAM MA, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2010
Last Update Date: 05/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5686 AGUA FRIA ST
SANTA FE NM
87507-9001
US

IV. Provider business mailing address

2215 RANCHO SIRINGO RD APT 1
SANTA FE NM
87505-5530
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-0586
  • Fax:
Mailing address:
  • Phone: 505-316-2726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0164631
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: