Healthcare Provider Details

I. General information

NPI: 1790792547
Provider Name (Legal Business Name): JADE WINTER MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2741 INDIAN SCHOOL RD NE
ALBUQUERQUE NM
87106-2653
US

IV. Provider business mailing address

3805 DOUGLAS MACARTHUR RD NE
ALBUQUERQUE NM
87110-1076
US

V. Phone/Fax

Practice location:
  • Phone: 505-205-7206
  • Fax: 505-255-7890
Mailing address:
  • Phone: 505-205-7206
  • Fax: 505-255-7890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0089441
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: