Healthcare Provider Details

I. General information

NPI: 1215254123
Provider Name (Legal Business Name): JENNIFER FIORDELISI MA, LPCC, MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2010
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 SAN PEDRO DR NE STE F1
ALBUQUERQUE NM
87110-4158
US

IV. Provider business mailing address

5717 ASPEN AVE NE
ALBUQUERQUE NM
87110-5213
US

V. Phone/Fax

Practice location:
  • Phone: 505-553-1725
  • Fax:
Mailing address:
  • Phone: 505-553-1725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0110261
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: