Healthcare Provider Details

I. General information

NPI: 1306342787
Provider Name (Legal Business Name): JEANETTE OLIVIA ANTUNEZ LISW (CSW), LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JEANETTE O LUCERO LPN

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 04/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 HERMOSA DR SE
ALBUQUERQUE NM
87108-4312
US

IV. Provider business mailing address

6901 QUARTERHORSE LN NW
ALBUQUERQUE NM
87120-3011
US

V. Phone/Fax

Practice location:
  • Phone: 505-237-0061
  • Fax:
Mailing address:
  • Phone: 505-899-7672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC-2702
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberC-2702
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: