Provider Demographics
NPI:1306342787
Name:ANTUNEZ, JEANETTE OLIVIA (LISW (CSW), LPN)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:OLIVIA
Last Name:ANTUNEZ
Suffix:
Gender:F
Credentials:LISW (CSW), LPN
Other - Prefix:
Other - First Name:JEANETTE
Other - Middle Name:O
Other - Last Name:LUCERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:6901 QUARTERHORSE LN NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-3011
Mailing Address - Country:US
Mailing Address - Phone:505-899-7672
Mailing Address - Fax:
Practice Address - Street 1:1025 HERMOSA DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-4312
Practice Address - Country:US
Practice Address - Phone:505-237-0061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-2702101Y00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor