Provider Demographics
NPI:1174272397
Name:WALLS, JEDEDIAH (LMHC, ATR-P)
Entity Type:Individual
Prefix:DR
First Name:JEDEDIAH
Middle Name:
Last Name:WALLS
Suffix:
Gender:M
Credentials:LMHC, ATR-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 GREENWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-5742
Mailing Address - Country:US
Mailing Address - Phone:574-310-3789
Mailing Address - Fax:
Practice Address - Street 1:133 WYATT DR STE 3
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2962
Practice Address - Country:US
Practice Address - Phone:575-526-9878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2022-0028101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health