Provider Demographics
NPI:1063178440
Name:BLACKWELL, JAY (MA, CPSW, LMHC)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:MA, CPSW, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 CARLISLE BLVD NE STE 105
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-1680
Mailing Address - Country:US
Mailing Address - Phone:056-524-6595
Mailing Address - Fax:
Practice Address - Street 1:3150 CARLISLE BLVD NE STE 105
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1680
Practice Address - Country:US
Practice Address - Phone:505-652-4659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-10
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTL0223091101YM0800X
NM1241175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMCTL0223091OtherNM REGULATION AND LICENSING DEPARTMENT
NM1241OtherOFFICE OF PEER RECOVERY AND ENGAGEMENT