Provider Demographics
NPI:1477004398
Name:JENNINGS-ALBALOS, DEZEREE DANIELLE
Entity Type:Individual
Prefix:MS
First Name:DEZEREE
Middle Name:DANIELLE
Last Name:JENNINGS-ALBALOS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:DEZEREE
Other - Middle Name:DANIELLE
Other - Last Name:SHANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5601 DOMINGO RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1610
Mailing Address - Country:US
Mailing Address - Phone:505-998-0045
Mailing Address - Fax:
Practice Address - Street 1:5601 DOMINGO RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1610
Practice Address - Country:US
Practice Address - Phone:505-268-5295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-14
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator