Healthcare Provider Details

I. General information

NPI: 1366532491
Provider Name (Legal Business Name): JENNIFER C. MCCASH LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 GRACELAND SE STE D
ALBUQUERQUE NM
87108
US

IV. Provider business mailing address

301 GRACELAND SE STE D
ALBUQUERQUE NM
87108
US

V. Phone/Fax

Practice location:
  • Phone: 505-203-8953
  • Fax: 505-344-8677
Mailing address:
  • Phone: 505-203-8953
  • Fax: 505-344-8677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-05551
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: