Healthcare Provider Details

I. General information

NPI: 1508511700
Provider Name (Legal Business Name): JENS BRAKENHOFF LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2022
Last Update Date: 06/27/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 SEAGULL ST NE STE B205
ALBUQUERQUE NM
87109-2500
US

IV. Provider business mailing address

6100 SEAGULL ST NE STE B205
ALBUQUERQUE NM
87109-2500
US

V. Phone/Fax

Practice location:
  • Phone: 505-377-1705
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2024-0429
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: