Provider Demographics
NPI:1861675415
Name:MYRICK, JACKIE (LMHC)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:MYRICK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7027 MONTGOMERY BLVD NE
Mailing Address - Street 2:SUITE F
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1589
Mailing Address - Country:US
Mailing Address - Phone:505-880-0100
Mailing Address - Fax:
Practice Address - Street 1:7027 MONTGOMERY BLVD NE
Practice Address - Street 2:SUITE F
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1589
Practice Address - Country:US
Practice Address - Phone:505-880-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4506101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health