Healthcare Provider Details

I. General information

NPI: 1841641479
Provider Name (Legal Business Name): JESSICA KOLAR LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA HARMON

II. Dates (important events)

Enumeration Date: 06/24/2016
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 BROADWAY BLVD NE STE 500
ALBUQUERQUE NM
87102-2367
US

IV. Provider business mailing address

PO BOX 1637
OWENSBORO KY
42302-1637
US

V. Phone/Fax

Practice location:
  • Phone: 505-268-0701
  • Fax: 270-689-6677
Mailing address:
  • Phone: 270-689-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCMH0202951
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0222881
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: