Healthcare Provider Details

I. General information

NPI: 1245345461
Provider Name (Legal Business Name): JENNIFER KLOSTERMAN RIELAGE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

5200 IRVING BLVD NW
ALBUQUERQUE NM
87114-4674
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone: 505-898-0203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY00003644
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: