Healthcare Provider Details

I. General information

NPI: 1790355477
Provider Name (Legal Business Name): MIMIR JOTTUN EVERETT MS, LCSW
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 RIO GRANDE BLVD NW STE G252
ALBUQUERQUE NM
87104-2050
US

IV. Provider business mailing address

901 RIO GRANDE BLVD NW STE G252
ALBUQUERQUE NM
87104-2050
US

V. Phone/Fax

Practice location:
  • Phone: 505-702-8112
  • Fax:
Mailing address:
  • Phone: 505-720-8112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number26642
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-11784
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: