Provider Demographics
NPI:1801239660
Name:FORSYTHE, JEANINE M (LPCC)
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:M
Last Name:FORSYTHE
Suffix:
Gender:
Credentials:LPCC
Other - Prefix:
Other - First Name:JEANINE
Other - Middle Name:M
Other - Last Name:MOREAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCC
Mailing Address - Street 1:7850 JEFFERSON ST NE STE 300
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4314
Mailing Address - Country:US
Mailing Address - Phone:505-884-1114
Mailing Address - Fax:505-884-3004
Practice Address - Street 1:3200 CARLISLE BLVD NE STE 225
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1664
Practice Address - Country:US
Practice Address - Phone:505-453-7307
Practice Address - Fax:505-293-0617
Is Sole Proprietor?:No
Enumeration Date:2013-04-11
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0113011101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM55172318Medicaid