Provider Demographics
NPI:1659735140
Name:CHARLEY, JENNIFER JOHN (LADAC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:JOHN
Last Name:CHARLEY
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 490
Mailing Address - Street 2:
Mailing Address - City:PINEHILL
Mailing Address - State:NM
Mailing Address - Zip Code:87357-0490
Mailing Address - Country:US
Mailing Address - Phone:505-775-3353
Mailing Address - Fax:505-775-3630
Practice Address - Street 1:15 BEHAVIORAL HEALTH RD
Practice Address - Street 2:
Practice Address - City:PINEHILL
Practice Address - State:NM
Practice Address - Zip Code:87357
Practice Address - Country:US
Practice Address - Phone:505-775-3353
Practice Address - Fax:505-775-3630
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0119271101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)