Healthcare Provider Details

I. General information

NPI: 1710461975
Provider Name (Legal Business Name): JENNIE DUNNELL LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2018
Last Update Date: 09/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1941 CAMINO RINCON SW
LOS LUNAS NM
87031-8842
US

IV. Provider business mailing address

1941 CAMINO RINCON SW
LOS LUNAS NM
87031-8842
US

V. Phone/Fax

Practice location:
  • Phone: 505-322-5856
  • Fax:
Mailing address:
  • Phone: 505-322-5856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-CTL0199261
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: