Healthcare Provider Details

I. General information

NPI: 1629904198
Provider Name (Legal Business Name): MARIAH KAYLA JAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 TRIBAL ROAD N7071 UNIT 3414
TOHAJIILEE NM
87026-5115
US

IV. Provider business mailing address

67 TRIBAL ROAD N7071 UNIT 3414
TOHAJIILEE NM
87026-5115
US

V. Phone/Fax

Practice location:
  • Phone: 505-373-7278
  • Fax:
Mailing address:
  • Phone: 505-373-7278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: