Provider Demographics
NPI:1841855277
Name:LABRADO, JENNIFER G
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:G
Last Name:LABRADO
Suffix:
Gender:F
Credentials:
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 70
Mailing Address - Street 2:MEDICAID SERVICES
Mailing Address - City:ANTHONY
Mailing Address - State:NM
Mailing Address - Zip Code:88021
Mailing Address - Country:US
Mailing Address - Phone:575-882-6101
Mailing Address - Fax:
Practice Address - Street 1:1451 DONALDSON AVE
Practice Address - Street 2:
Practice Address - City:ANTHONY
Practice Address - State:NM
Practice Address - Zip Code:88021-8103
Practice Address - Country:US
Practice Address - Phone:575-662-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSLPA66632355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant