Provider Demographics
NPI:1710105879
Name:MINARSICH-NOBLE, JENNIFER REBECCA (MA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:REBECCA
Last Name:MINARSICH-NOBLE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 CAMINO DEL SOL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-1531
Mailing Address - Country:US
Mailing Address - Phone:505-550-1607
Mailing Address - Fax:505-212-0040
Practice Address - Street 1:707 BROADWAY BLVD NE
Practice Address - Street 2:SUITE 103
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2360
Practice Address - Country:US
Practice Address - Phone:505-766-9361
Practice Address - Fax:505-166-9157
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0069482101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health