Healthcare Provider Details

I. General information

NPI: 1922299460
Provider Name (Legal Business Name): JILL ANNE FERNANDEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N 2ND ST
RATON NM
87740-3803
US

IV. Provider business mailing address

2632 AGUILAR DR
TRINIDAD CO
81082-3937
US

V. Phone/Fax

Practice location:
  • Phone: 575-445-7090
  • Fax:
Mailing address:
  • Phone: 719-859-0347
  • Fax: 719-859-0347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-08359
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: