Healthcare Provider Details

I. General information

NPI: 1093258378
Provider Name (Legal Business Name): JENNIFER MICHELLE ESPINOSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2016
Last Update Date: 02/17/2020
Certification Date: 02/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5203 JUAN TABO BLVD NE STE 2A
ALBUQUERQUE NM
87111-2691
US

IV. Provider business mailing address

5203 JUAN TABO BLVD NE STE 2A
ALBUQUERQUE NM
87111-2691
US

V. Phone/Fax

Practice location:
  • Phone: 505-266-6121
  • Fax:
Mailing address:
  • Phone: 505-266-6121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCMH0209921
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: