Basic Information
| Provider Information | |||||||||
| NPI: | 1538834262 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JURGENSEN | ||||||||
| FirstName: | NANETTE | ||||||||
| MiddleName: | DENICE | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12101 OAKLAND AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871222270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057205709 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2612 TEXAS ST NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871104684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058301871 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2021 | ||||||||
| LastUpdateDate: | 08/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | X-12016 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | X-12016 | 01 | NM | MEDICARE | OTHER | X-12016 | 05 | NM | MEDICAID |