Healthcare Provider Details

I. General information

NPI: 1386405678
Provider Name (Legal Business Name): JENNIFER CLYSDALE MSN, CNP, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2024
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7850 JEFFERSON ST NE STE 300
ALBUQUERQUE NM
87109-4314
US

IV. Provider business mailing address

7850 JEFFERSON ST NE STE 300
ALBUQUERQUE NM
87109-4314
US

V. Phone/Fax

Practice location:
  • Phone: 505-884-1114
  • Fax: 505-359-3010
Mailing address:
  • Phone: 505-884-1114
  • Fax: 505-359-3010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number58064
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: