Provider Demographics
NPI:1023434198
Name:CROCKETT, JENNAFER JOLLEEN (LMHC, MFT)
Entity type:Individual
Prefix:MRS
First Name:JENNAFER
Middle Name:JOLLEEN
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:LMHC, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E EARLL DR STE 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2647
Mailing Address - Country:US
Mailing Address - Phone:575-623-1480
Mailing Address - Fax:575-622-3325
Practice Address - Street 1:1010 S GARDEN AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-6866
Practice Address - Country:US
Practice Address - Phone:575-623-7660
Practice Address - Fax:575-623-2604
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-12
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0172701101YM0800X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker