Basic Information
| Provider Information | |||||||||
| NPI: | 1922501931 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JARAMILLO-AVILA | ||||||||
| FirstName: | ANGEL | ||||||||
| MiddleName: | J | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 907 | ||||||||
| Address2: | |||||||||
| City: | HOBBS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753933168 | ||||||||
| FaxNumber: | 5753923969 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 W BROADWAY | ||||||||
| Address2: | |||||||||
| City: | HOBBS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753933168 | ||||||||
| FaxNumber: | 5753974659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2018 | ||||||||
| LastUpdateDate: | 10/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 106S00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | 00046300 | 05 | NM | MEDICAID |