Provider Demographics
NPI:1255757704
Name:GRAJEDA, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GRAJEDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 SOL DE VIDA NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1396
Mailing Address - Country:US
Mailing Address - Phone:505-730-6726
Mailing Address - Fax:
Practice Address - Street 1:ALL FAITHS CHILDREN'S ADVOCACY CENTER
Practice Address - Street 2:8401 CONSTITUTION AVE NE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-271-0329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-07
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCMH0201601101YP2500X
NMT-0177061101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional