Provider Demographics
NPI:1346719440
Name:JUAN, JANICE ALTA
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:ALTA
Last Name:JUAN
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 1:5851 ANDERSON AVE SE APT 81
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-5413
Mailing Address - Country:US
Mailing Address - Phone:505-239-6106
Mailing Address - Fax:
Practice Address - Street 1:100 DEPUTY DEAN MIERA DR SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87151-1000
Practice Address - Country:US
Practice Address - Phone:505-839-8974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-10622104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker