Healthcare Provider Details

I. General information

NPI: 1679679369
Provider Name (Legal Business Name): JENNIFER LYNNE GILLESPIE LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 08/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2074 GALISTEO ST SUITE B-3
SANTA FE NM
87505-2138
US

IV. Provider business mailing address

4153 RAINDANCE LN
SANTA FE NM
87507-2621
US

V. Phone/Fax

Practice location:
  • Phone: 505-231-3047
  • Fax:
Mailing address:
  • Phone: 505-231-3047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0088651
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: