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General NPI Number Information
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NPI Number | 1811442932
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Entity Type | Individual
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Provider Name | PRISCILLA A JAKE LMHC
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Gender | Female
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Dates
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Enumeration Date | 08/18/2016
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Last Update Date | 04/01/2025
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Provider Practice Location Address
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Address Line | 1615 OJO COURT
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City | FARMINGTON
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State | NM
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Zip | 87499
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Country | US
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Telephone | 505-564-4804
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Fax |
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Provider Business Mailing Address
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Address Line | P. O. BOX 14
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City | FARMINGTON
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State | NM
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Zip | 87499
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | CTB-2022-0810
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License Number State | NM
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