Healthcare Provider Details

I. General information

NPI: 1801620729
Provider Name (Legal Business Name): JENNA KOORS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2024
Last Update Date: 09/02/2024
Certification Date: 09/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 KELLY LYNN DR
SANDIA PARK NM
87047-9326
US

IV. Provider business mailing address

20 KELLY LYNN DR
SANDIA PARK NM
87047-9326
US

V. Phone/Fax

Practice location:
  • Phone: 505-363-9373
  • Fax:
Mailing address:
  • Phone: 505-363-9373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MISS JENNA MARIE KOORS
Title or Position: PSYCHOTHERAPIST/CEO
Credential: LCSW
Phone: 505-363-9373