Healthcare Provider Details

I. General information

NPI: 1720444664
Provider Name (Legal Business Name): JENNIFER A URBAN LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2016
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 YALE BLVD NE
ALBUQUERQUE NM
87106-3825
US

IV. Provider business mailing address

3901 INDIAN SCHOOL RD NE APT D205
ALBUQUERQUE NM
87110-3852
US

V. Phone/Fax

Practice location:
  • Phone: 505-573-4407
  • Fax:
Mailing address:
  • Phone: 505-573-4407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0172631
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0213981
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: