Provider Demographics
NPI:1760615140
Name:CALLAWAY, JESSICA LYNN (LPCC)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:LYNN
Last Name:CALLAWAY
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 A PASEO DE ONATE
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532
Mailing Address - Country:US
Mailing Address - Phone:505-852-1377
Mailing Address - Fax:505-852-1378
Practice Address - Street 1:1102 A PASEO DE ONATE
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532
Practice Address - Country:US
Practice Address - Phone:505-852-1377
Practice Address - Fax:505-852-1378
Is Sole Proprietor?:No
Enumeration Date:2009-09-01
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0120981101YM0800X
NM0113441101YM0800X
NM0132841101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health