Provider Demographics
NPI:1811442932
Name:JAKE, PRISCILLA A (LMHC)
Entity type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:A
Last Name:JAKE
Suffix:
Gender:
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:P. O. BOX 14
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1615 OJO COURT
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87499
Practice Address - Country:US
Practice Address - Phone:505-564-4804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2022-0810101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health