Provider Demographics
NPI:1326402199
Name:CROCKETT, JAMIE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:CROCKETT
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 1:530 DE MOSS ST
Mailing Address - Street 2:
Mailing Address - City:LORDSBURG
Mailing Address - State:NM
Mailing Address - Zip Code:88045-2618
Mailing Address - Country:US
Mailing Address - Phone:575-542-2369
Mailing Address - Fax:
Practice Address - Street 1:530 DE MOSS ST
Practice Address - Street 2:
Practice Address - City:LORDSBURG
Practice Address - State:NM
Practice Address - Zip Code:88045-2618
Practice Address - Country:US
Practice Address - Phone:575-542-2369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-07
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA466176B00000X
NMCTB-2022-0048101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No176B00000XOther Service ProvidersMidwife