Healthcare Provider Details

I. General information

NPI: 1962716795
Provider Name (Legal Business Name): JENNIFER DAVIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 YALE BLVD SE
ALBUQUERQUE NM
87106-4383
US

IV. Provider business mailing address

1817 CARLISLE BLVD NE
ALBUQUERQUE NM
87110-4905
US

V. Phone/Fax

Practice location:
  • Phone: 505-994-0000
  • Fax:
Mailing address:
  • Phone: 505-842-9911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number06987
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-08551
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: