Provider Demographics
NPI:1194157271
Name:VIGIL, JENNIFER P (LADAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:P
Last Name:VIGIL
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 969
Mailing Address - Street 2:
Mailing Address - City:OHKAY OWINGEH
Mailing Address - State:NM
Mailing Address - Zip Code:87566-0969
Mailing Address - Country:US
Mailing Address - Phone:505-852-1377
Mailing Address - Fax:
Practice Address - Street 1:1102 A PASEO DE ONATE
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87533
Practice Address - Country:US
Practice Address - Phone:505-852-1377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3503101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)