Provider Demographics
NPI:1124231618
Name:WEST, JACKIE LYNNE (LPCC, LADAC)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYNNE
Last Name:WEST
Suffix:
Gender:F
Credentials:LPCC, LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 CAMINO ENTRADA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-4851
Mailing Address - Country:US
Mailing Address - Phone:505-216-2727
Mailing Address - Fax:505-365-1006
Practice Address - Street 1:5400 GIBSON BLVD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5566
Practice Address - Country:US
Practice Address - Phone:505-841-8978
Practice Address - Fax:505-841-8977
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4749101YA0400X
NMT-0098501101YM0800X
NMCTB-2022-0948101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health