Provider Demographics
NPI:1376563049
Name:SCHNEIDER, JOLENE M (LADAC)
Entity Type:Individual
Prefix:MS
First Name:JOLENE
Middle Name:M
Last Name:SCHNEIDER
Suffix:
Gender:F
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1830
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-1830
Mailing Address - Country:US
Mailing Address - Phone:505-327-7218
Mailing Address - Fax:505-327-0828
Practice Address - Street 1:1313 MISSION AVENUE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5638
Practice Address - Country:US
Practice Address - Phone:505-327-7218
Practice Address - Fax:505-327-0828
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3473101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM26175754Medicaid