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General NPI Number Information
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NPI Number | 1639648736
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Entity Type | Individual
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Provider Name | JENNIFER NELSON LCSW
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Gender | Female
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Dates
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Enumeration Date | 11/19/2018
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Last Update Date | 07/21/2024
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Provider Practice Location Address
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Address Line | 215 COWBOY WAY
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City | EDGEWOOD
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State | NM
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Zip | 87015-9616
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Country | US
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Telephone | 505-464-7213
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1080
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City | ESTANCIA
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State | NM
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Zip | 87016-1080
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Country | US
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Telephone | 505-750-0105
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C-12014
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License Number State | NM
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