Healthcare Provider Details

I. General information

NPI: 1285345942
Provider Name (Legal Business Name): JILL GRIFFIN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2022
Last Update Date: 12/13/2022
Certification Date: 12/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 APACHE PLUME DRIVE
SANTA FE NM
87508
US

IV. Provider business mailing address

23 APACHE PLUME DRIVE
SANTA FE NM
87508
US

V. Phone/Fax

Practice location:
  • Phone: 575-613-2143
  • Fax:
Mailing address:
  • Phone: 575-613-2143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCAD005677
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: