Basic Information
| Provider Information | |||||||||
| NPI: | 1649251943 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REAGAN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9016 LOS ARBOLES AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871121269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053320817 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2600 MARBLE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722190 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | I-3305 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 000L1672 | 05 | NM | MEDICAID |