Basic Information
| Provider Information | |||||||||
| NPI: | 1669020285 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRISCUOLO | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2612 TEXAS ST NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871104684 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4001 OFFICE COURT DR STE 603 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875074905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058301871 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2019 | ||||||||
| LastUpdateDate: | 08/27/2019 | ||||||||
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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 | 104100000X | X-11021 | NM | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.