Healthcare Provider Details

I. General information

NPI: 1679002448
Provider Name (Legal Business Name): JENNIFER L CARRASCO CLC , CD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1341 COLUMBIA AVE
ALAMOGORDO NM
88310-8012
US

IV. Provider business mailing address

1341 COLUMBIA AVE
ALAMOGORDO NM
88310-8012
US

V. Phone/Fax

Practice location:
  • Phone: 575-404-1717
  • Fax: 575-404-1717
Mailing address:
  • Phone: 575-404-1717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberALPP-258224
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: