Provider Demographics
NPI:1851883953
Name:MIXON, JADE MONIQUE (LCSW)
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:MONIQUE
Last Name:MIXON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1058 S AVENIDA DEL ORO E
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-2072
Mailing Address - Country:US
Mailing Address - Phone:719-569-5653
Mailing Address - Fax:
Practice Address - Street 1:3915 OUTLOOK BLVD STE B2
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2604
Practice Address - Country:US
Practice Address - Phone:719-569-5653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099243611041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical