Basic Information
| Provider Information | |||||||||
| NPI: | 1336346832 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OBERLY WOLF | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LAUREN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OBERLY | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | LAUREN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA, LMFT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2960 RODEO PARK DR W | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875056351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109869633 | ||||||||
| FaxNumber: | 5054744663 | ||||||||
| Practice Location | |||||||||
| Address1: | 2960 RODEO PARK DR W | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059869633 | ||||||||
| FaxNumber: | 5054744663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2007 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | LMFT52395 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | MFC 52395 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | CMF0206341 | NM | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.