Basic Information
| Provider Information | |||||||||
| NPI: | 1255757704 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAJEDA | ||||||||
| FirstName: | JACQUELINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 SOL DE VIDA NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871201396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057306726 | ||||||||
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| Practice Location | |||||||||
| Address1: | ALL FAITHS CHILDREN'S ADVOCACY CENTER | ||||||||
| Address2: | 8401 CONSTITUTION AVE NE | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052710329 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2014 | ||||||||
| LastUpdateDate: | 05/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | CCMH0201601 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | T-0177061 | NM | N | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.