Healthcare Provider Details

I. General information

NPI: 1275869141
Provider Name (Legal Business Name): JENNIFER L. BECENTI LADAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2009
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SOUTHWEST HIGHLAND DRIVE
CROWNPOINT NM
87313
US

IV. Provider business mailing address

P.O. BOX 1144
CROWNPOINT NM
87313-1144
US

V. Phone/Fax

Practice location:
  • Phone: 505-786-2111
  • Fax: 505-786-2020
Mailing address:
  • Phone: 505-786-2111
  • Fax: 505-786-5442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0120441
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: