Healthcare Provider Details

I. General information

NPI: 1316372501
Provider Name (Legal Business Name): MINDY JITMANOWAN PSY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2013
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 CONSTITUTION AVE NE BLDG D
ALBUQUERQUE NM
87110-7613
US

IV. Provider business mailing address

PO BOX 26666 PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-2402
  • Fax:
Mailing address:
  • Phone: 505-923-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY1623
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: