Healthcare Provider Details

I. General information

NPI: 1104851534
Provider Name (Legal Business Name): JILL M TIEDEMANN LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601A SAINT MICHAELS DR
SANTA FE NM
87505-7614
US

IV. Provider business mailing address

1601A SAINT MICHAELS DR
SANTA FE NM
87505-7614
US

V. Phone/Fax

Practice location:
  • Phone: 505-954-8777
  • Fax: 505-954-8793
Mailing address:
  • Phone: 505-954-8777
  • Fax: 505-954-8793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT3476
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: