Provider Demographics
NPI:1487721130
Name:FAILLA, JENNIFER HOPE (LPCC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HOPE
Last Name:FAILLA
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 PONDEROSA DR
Mailing Address - Street 2:
Mailing Address - City:JEMEZ SPRINGS
Mailing Address - State:NM
Mailing Address - Zip Code:87025-8116
Mailing Address - Country:US
Mailing Address - Phone:505-829-4512
Mailing Address - Fax:505-829-4512
Practice Address - Street 1:4477 IRVING BLVD NW STE B
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5529
Practice Address - Country:US
Practice Address - Phone:575-933-1978
Practice Address - Fax:575-339-2780
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0073611101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM23805234Medicaid