Healthcare Provider Details

I. General information

NPI: 1396808507
Provider Name (Legal Business Name): JAN E UNNA LPCC, LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 GALISTEO ST SUITE N-2
SANTA FE NM
87505-2143
US

IV. Provider business mailing address

1719 CALLEJON CORDELIA
SANTA FE NM
87501-2309
US

V. Phone/Fax

Practice location:
  • Phone: 505-989-8418
  • Fax: 505-955-1732
Mailing address:
  • Phone: 505-995-0307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0088491
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: