Provider Demographics
NPI:1578651386
Name:VISCAYA, JENNA (LMHC, DOM)
Entity Type:Individual
Prefix:DR
First Name:JENNA
Middle Name:
Last Name:VISCAYA
Suffix:
Gender:F
Credentials:LMHC, DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205B SCHOOL OF MINES RD
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801-4545
Mailing Address - Country:US
Mailing Address - Phone:505-946-7030
Mailing Address - Fax:
Practice Address - Street 1:205 SCHOOL OF MINES RD
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-4545
Practice Address - Country:US
Practice Address - Phone:575-835-4787
Practice Address - Fax:575-835-4787
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0088591101YM0800X
171M00000X
NM558171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator