Provider Demographics
NPI:1053183061
Name:PENNER, ISAAC JORDAN (MA, LMHC)
Entity type:Individual
Prefix:
First Name:ISAAC
Middle Name:JORDAN
Last Name:PENNER
Suffix:
Gender:M
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8916 ARKANSAS RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-3991
Mailing Address - Country:US
Mailing Address - Phone:505-379-4035
Mailing Address - Fax:
Practice Address - Street 1:3811 ATRISCO DR NW STE D
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-4903
Practice Address - Country:US
Practice Address - Phone:505-379-4035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2023-0303101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health