Provider Demographics
NPI:1679002448
Name:CARRASCO, JENNIFER L (CLC , CD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:CARRASCO
Suffix:
Gender:F
Credentials:CLC , CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1341 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-8012
Mailing Address - Country:US
Mailing Address - Phone:575-404-1717
Mailing Address - Fax:
Practice Address - Street 1:1341 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-8012
Practice Address - Country:US
Practice Address - Phone:575-404-1717
Practice Address - Fax:575-404-1717
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-06
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAALPP-258224174N00000X
NM374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No174N00000XOther Service ProvidersLactation Consultant, Non-RN