Provider Demographics
NPI:1164842134
Name:ANDERMANN, JENNIFER M
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:ANDERMANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 N DATE ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901-2377
Mailing Address - Country:US
Mailing Address - Phone:575-894-7589
Mailing Address - Fax:575-894-7584
Practice Address - Street 1:405 N DATE ST
Practice Address - Street 2:SUITE 8
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-2377
Practice Address - Country:US
Practice Address - Phone:575-894-7589
Practice Address - Fax:575-894-7584
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-17
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-050871041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMI-05087OtherNM STATE LISW LICENSE