Provider Demographics
NPI:1487022919
Name:JACKSON, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 SHAWNEE TRL
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-4020
Mailing Address - Country:US
Mailing Address - Phone:575-491-5459
Mailing Address - Fax:
Practice Address - Street 1:3205 SHAWNEE TRL
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310
Practice Address - Country:US
Practice Address - Phone:575-491-5459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-15
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician