Provider Demographics
NPI:1275801078
Name:WILLIAMS, JACKSON NEAL (LMHC)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:NEAL
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 GOLDEN YARROW TRL
Mailing Address - Street 2:
Mailing Address - City:BERNALILLO
Mailing Address - State:NM
Mailing Address - Zip Code:87004-5780
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 GOLDEN YARROW TRL
Practice Address - Street 2:
Practice Address - City:BERNALILLO
Practice Address - State:NM
Practice Address - Zip Code:87004-5780
Practice Address - Country:US
Practice Address - Phone:505-227-4909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-07
Last Update Date:2012-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0151041101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health