Healthcare Provider Details

I. General information

NPI: 1508297698
Provider Name (Legal Business Name): JENNIE MCCRAW LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2013
Last Update Date: 11/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1033 MESA RIDGE DR SW
LOS LUNAS NM
87031-6189
US

IV. Provider business mailing address

1033 MESA RIDGE DR SW
LOS LUNAS NM
87031-6189
US

V. Phone/Fax

Practice location:
  • Phone: 505-385-5829
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-2741
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: