=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922519735
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JADE THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2017
-----------------------------------------------------
Last Update Date | 08/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1505 15TH ST STE C
-----------------------------------------------------
City | LOS ALAMOS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87544-3000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-692-9513
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1006 PASEO DE LA CUMA
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87501-1221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-692-9513
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | MRS. CLAIRE JULIA WOOD
-----------------------------------------------------
Credential | LPCC
-----------------------------------------------------
Telephone | 505-692-9513
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 0189841
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------