Provider Demographics
NPI:1265077275
Name:JAMES, JERRALD TOM (LADAC, LMSW)
Entity type:Individual
Prefix:MR
First Name:JERRALD
Middle Name:TOM
Last Name:JAMES
Suffix:
Gender:M
Credentials:LADAC, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 E 20TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2132
Mailing Address - Country:US
Mailing Address - Phone:505-327-0293
Mailing Address - Fax:505-564-4925
Practice Address - Street 1:475 E 20TH ST STE D
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2132
Practice Address - Country:US
Practice Address - Phone:505-327-0293
Practice Address - Fax:505-564-4925
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCAD0205831101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)