Provider Demographics
NPI:1023501996
Name:TRUJILLO, JAY (LMSW)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:TRUJILLO
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3665 CERRILLOS RD TRLR 2
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-2953
Mailing Address - Country:US
Mailing Address - Phone:505-231-9793
Mailing Address - Fax:
Practice Address - Street 1:85 WEST HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:KEWA PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87052
Practice Address - Country:US
Practice Address - Phone:505-465-3060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NMSWB-2024-0293104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician