Healthcare Provider Details

I. General information

NPI: 1770949323
Provider Name (Legal Business Name): JILLIAN EVANS LMHC, ATR-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2016
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 LOUISIANA BLVD NE
ALBUQUERQUE NM
87110-3532
US

IV. Provider business mailing address

2900 LOUISIANA BLVD NE
ALBUQUERQUE NM
87110-3532
US

V. Phone/Fax

Practice location:
  • Phone: 505-220-8512
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0178661
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: