| Jen Willis Lisw | |
|
2111 Golf Course Rd Se Ste D Rio Rancho NM 87124-1634 | |
| (505) 639-1312 | |
| Not Available |
| Full Name | Jen Willis Lisw |
|---|---|
| Speciality | Counselor |
| Location | 2111 Golf Course Rd Se Ste D, Rio Rancho, New Mexico |
| Authorized Official Name and Position | Jennifer Beth Rose (SOLE PROPRIETOR) |
| Authorized Official Contact | 5056391312 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Jen Willis Lisw 2111 Golf Course Rd Se Ste D Rio Rancho NM 87124-1634 Ph: (505) 639-1312 | Jen Willis Lisw 2111 Golf Course Rd Se Ste D Rio Rancho NM 87124-1634 Ph: (505) 639-1312 |
| NPI Number | 1598218190 |
|---|---|
| Provider Enumeration Date | 07/29/2016 |
| Last Update Date | 09/04/2024 |
| Certification Date | 09/04/2024 |
| Medicare PECOS PAC ID | 5496039752 |
|---|---|
| Medicare Enrollment ID | O20170306000314 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1598218190 | NPI | - | NPPES |
| 02351714 | Medicaid | NM | |
| 1598218190 | Other | NPI TYPE 2 | |
| 17301866 | Medicaid | NM | |
| 1104864255 | Other | NM | NPI TYPE 1 |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | I-06999 (New Mexico) | Primary |
| Provider Name | Jennifer B Willis |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1104864255 PECOS PAC ID: 6305120668 Enrollment ID: I20170306000368 |
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