Healthcare Provider Details

I. General information

NPI: 1174272397
Provider Name (Legal Business Name): JEDEDIAH WALLS LMHC, ATR-P
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 CERRILLOS RD STE 724D
SANTA FE NM
87507-2690
US

IV. Provider business mailing address

3600 CERRILLOS RD STE 724D
SANTA FE NM
87507-2690
US

V. Phone/Fax

Practice location:
  • Phone: 575-342-9178
  • Fax: 575-252-4994
Mailing address:
  • Phone: 575-342-9178
  • Fax: 575-252-4994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2022-0028
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: