Basic Information
| Provider Information | |||||||||
| NPI: | 1356737654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARTER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
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| Credential: | MA, LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9200 CASCAJO DR NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871112206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7246140375 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1218 GRIEGOS RD NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871073752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053458471 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2015 | ||||||||
| LastUpdateDate: | 10/27/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0173441 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 04972074 | 05 | NM | MEDICAID |