Provider Demographics
NPI:1851887806
Name:MAYES, JASMINE M
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:M
Last Name:MAYES
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 1:807 W APACHE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5527
Mailing Address - Country:US
Mailing Address - Phone:505-325-5358
Mailing Address - Fax:505-326-3085
Practice Address - Street 1:807 W APACHE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5527
Practice Address - Country:US
Practice Address - Phone:505-325-5358
Practice Address - Fax:505-326-3085
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM21138761Medicaid