Healthcare Provider Details

I. General information

NPI: 1205317047
Provider Name (Legal Business Name): JENNIFER L BEAR LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2632 PENNSYLVANIA ST NE STE E
ALBUQUERQUE NM
87110
US

IV. Provider business mailing address

2809 PALO VERDE DR NE APT B
ALBUQUERQUE NM
87112-2142
US

V. Phone/Fax

Practice location:
  • Phone: 242-440-0505
  • Fax:
Mailing address:
  • Phone: 727-465-4555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberT-CTL0198901
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: