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General NPI Number Information
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NPI Number | 1043376288
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Entity Type | Organization
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Legal Business Name | JACK L. HUMPHRIES, LISW, LTD.
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Dates
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Enumeration Date | 12/30/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 8800 PALOMAR AVE NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87109-7205
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Country | US
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Telephone | 505-620-5225
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Fax | 505-798-1743
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Provider Business Mailing Address
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Address Line | PO BOX 16387
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City | ALBUQUERQUE
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State | NM
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Zip | 87191-6387
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Country | US
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Telephone | 505-620-5225
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Fax | 505-798-1743
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. JACK L. HUMPHRIES
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Credential | LISW
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Telephone | 505-620-5225
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | I-3613
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License Number State | NM
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