Provider Demographics
NPI:1558900209
Name:JAKEWAY, ELIZABETH RUTH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:RUTH
Last Name:JAKEWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:BUSCH
Other - Last Name:JAKEWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1700 N COCHITI AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-7080
Mailing Address - Country:US
Mailing Address - Phone:505-635-0753
Mailing Address - Fax:
Practice Address - Street 1:1700 N COCHITI AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-7080
Practice Address - Country:US
Practice Address - Phone:505-635-0753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-29
Last Update Date:2019-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician