Healthcare Provider Details

I. General information

NPI: 1043802507
Provider Name (Legal Business Name): JENNIFER PALUMBO LCDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2021
Last Update Date: 02/05/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 MONTANO RD NW STE G1
ALBUQUERQUE NM
87120-1826
US

IV. Provider business mailing address

6300 MONTANO RD NW STE G1
ALBUQUERQUE NM
87120-1826
US

V. Phone/Fax

Practice location:
  • Phone: 505-999-0203
  • Fax: 505-521-5161
Mailing address:
  • Phone: 505-999-0203
  • Fax: 505-521-5161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10992
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: