Provider Demographics
NPI:1679679369
Name:GILLESPIE, JENNIFER LYNNE (LPCC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNNE
Last Name:GILLESPIE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4153 RAINDANCE LN
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-2621
Mailing Address - Country:US
Mailing Address - Phone:505-231-3047
Mailing Address - Fax:
Practice Address - Street 1:2074 GALISTEO ST
Practice Address - Street 2:SUITE B-3
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2138
Practice Address - Country:US
Practice Address - Phone:505-231-3047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0088651101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM89955781Medicaid