Healthcare Provider Details

I. General information

NPI: 1427243542
Provider Name (Legal Business Name): JENNIFER LIANE COOK LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER LIANE MALLICH LPC

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 RIO GRANDE BLVD. SE SUITE D
RIO RANCHO NM
87124
US

IV. Provider business mailing address

2320 RIO GRANDE BLVD. SE SUITE D
RIO RANCHO NM
87124
US

V. Phone/Fax

Practice location:
  • Phone: 505-219-1125
  • Fax:
Mailing address:
  • Phone: 505-219-1125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCCMH0180961
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: