Healthcare Provider Details

I. General information

NPI: 1649251943
Provider Name (Legal Business Name): JENNIFER L REAGAN LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MARBLE NE
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

9016 LOS ARBOLES AVE NE
ALBUQUERQUE NM
87112-1269
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2190
  • Fax:
Mailing address:
  • Phone: 505-332-0817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberI-3305
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: