Provider Demographics
NPI:1679653042
Name:JASPER, REBECCA G (MSW ACSW LISW)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:G
Last Name:JASPER
Suffix:
Gender:F
Credentials:MSW ACSW LISW
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 3602
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-3062
Mailing Address - Country:US
Mailing Address - Phone:505-326-0241
Mailing Address - Fax:505-325-8356
Practice Address - Street 1:2901 E 20TH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-4411
Practice Address - Country:US
Practice Address - Phone:505-326-0241
Practice Address - Fax:505-325-8356
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI2737103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMF5718Medicaid