Healthcare Provider Details

I. General information

NPI: 1336598945
Provider Name (Legal Business Name): JANE DAVIS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2016
Last Update Date: 06/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 E OLD AGUA FRIA RD
SANTA FE NM
87508-5970
US

IV. Provider business mailing address

756 BACA ST
SANTA FE NM
87505-0975
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-1169
  • Fax:
Mailing address:
  • Phone: 505-670-1844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-07029
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: