Healthcare Provider Details

I. General information

NPI: 1407365737
Provider Name (Legal Business Name): JARED ROBERT WHITTINGTON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 09/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 WYOMING BLVD NE
ALBUQUERQUE NM
87123-1038
US

IV. Provider business mailing address

600 WYOMING BLVD NE
ALBUQUERQUE NM
87123-1038
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4792
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: