Provider Demographics
NPI:1104817303
Name:JACKSON, GAIL E (LISW)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 CALLE DEL RANCHERO NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-1906
Mailing Address - Country:US
Mailing Address - Phone:505-256-4742
Mailing Address - Fax:
Practice Address - Street 1:625 TRUMAN ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6443
Practice Address - Country:US
Practice Address - Phone:505-272-6916
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-0090101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM80529275Medicaid