Provider Demographics
NPI:1215254123
Name:FIORDELISI, JENNIFER (MA, LPCC, MA)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:FIORDELISI
Suffix:
Gender:F
Credentials:MA, LPCC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5717 ASPEN AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5213
Mailing Address - Country:US
Mailing Address - Phone:505-553-1725
Mailing Address - Fax:
Practice Address - Street 1:2315 SAN PEDRO DR NE STE F1
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4158
Practice Address - Country:US
Practice Address - Phone:505-553-1725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-02
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0110261101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM49381857Medicaid
NMNONE GIVENOtherTRICARE
NMNONE GIVENOtherBLUE CROSS BLUE SHIELD