Healthcare Provider Details

I. General information

NPI: 1285053132
Provider Name (Legal Business Name): JEFF WAYNE PONTES LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2014
Last Update Date: 10/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 SILVER AVE SE STE F
ALBUQUERQUE NM
87108-2748
US

IV. Provider business mailing address

621 WALTER ST
ALBUQUERQUE NM
87102
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-1804
  • Fax:
Mailing address:
  • Phone: 505-918-7955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0170131
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: