Provider Demographics
NPI:1730257676
Name:ROBERTS, JEAN SPARHAWK (LISW)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:SPARHAWK
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 TULANE PL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2153
Mailing Address - Country:US
Mailing Address - Phone:505-268-1480
Mailing Address - Fax:505-268-1480
Practice Address - Street 1:2403 SAN MATEO BLVD NE
Practice Address - Street 2:S-15
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4058
Practice Address - Country:US
Practice Address - Phone:505-268-1480
Practice Address - Fax:505-268-1480
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-21621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical