Provider Demographics
NPI:1699925594
Name:DUNGAN, JEANNETTE ELENA
Entity type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:ELENA
Last Name:DUNGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S MAIN ST STE 249
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1243
Mailing Address - Country:US
Mailing Address - Phone:575-527-5823
Mailing Address - Fax:
Practice Address - Street 1:505 N. MAIN STREET STE. 249
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001
Practice Address - Country:US
Practice Address - Phone:575-527-9430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-26
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM329968103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool