Provider Demographics
NPI:1265676803
Name:ERICKSON, JODY LEIGH (DOM, DA)
Entity Type:Individual
Prefix:DR
First Name:JODY
Middle Name:LEIGH
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:DOM, DA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2468
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87504-2468
Mailing Address - Country:US
Mailing Address - Phone:505-474-4550
Mailing Address - Fax:
Practice Address - Street 1:1472 1/2 S SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4038
Practice Address - Country:US
Practice Address - Phone:505-474-4550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM146171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist