Healthcare Provider Details

I. General information

NPI: 1639648736
Provider Name (Legal Business Name): JENNIFER NELSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2018
Last Update Date: 07/21/2024
Certification Date: 07/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 COWBOY WAY
EDGEWOOD NM
87015-9616
US

IV. Provider business mailing address

PO BOX 1080
ESTANCIA NM
87016-1080
US

V. Phone/Fax

Practice location:
  • Phone: 505-464-7213
  • Fax:
Mailing address:
  • Phone: 505-750-0105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-12014
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: