Provider Demographics
NPI:1649265711
Name:SANDOVAL, JENNIFER (LADAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SANDOVAL
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 640
Mailing Address - Street 2:
Mailing Address - City:ISLETA
Mailing Address - State:NM
Mailing Address - Zip Code:87022
Mailing Address - Country:US
Mailing Address - Phone:505-869-5474
Mailing Address - Fax:505-869-4584
Practice Address - Street 1:01 SAGEBRUSH STREET
Practice Address - Street 2:
Practice Address - City:ISLETA
Practice Address - State:NM
Practice Address - Zip Code:87022
Practice Address - Country:US
Practice Address - Phone:505-869-5474
Practice Address - Fax:505-869-4584
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3850101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)