Basic Information
Provider Information | |||||||||
NPI: | 1235322322 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ORDAZ | ||||||||
FirstName: | JACKIE | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6621 DONIPHAN DR STE G | ||||||||
Address2: |   | ||||||||
City: | CANUTILLO | ||||||||
State: | TX | ||||||||
PostalCode: | 798355005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9158775100 | ||||||||
FaxNumber: | 9158775107 | ||||||||
Practice Location | |||||||||
Address1: | 6621 DONIPHAN DR STE G | ||||||||
Address2: |   | ||||||||
City: | CANUTILLO | ||||||||
State: | TX | ||||||||
PostalCode: | 798355005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9158775100 | ||||||||
FaxNumber: | 9158775107 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/22/2007 | ||||||||
LastUpdateDate: | 08/22/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | X-05978 | NM | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
ID Information
ID | Type | State | Issuer | Description | VNM30451NI | 05 | NM |   | MEDICAID |