Healthcare Provider Details

I. General information

NPI: 1194366260
Provider Name (Legal Business Name): JENA M LOVATO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2019
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 E BASELINE RD STE 109
MESA AZ
85206-4403
US

IV. Provider business mailing address

2332 VIA GRANADA PL NW
ALBUQUERQUE NM
87104-3097
US

V. Phone/Fax

Practice location:
  • Phone: 480-818-4212
  • Fax:
Mailing address:
  • Phone: 505-205-3472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA12084
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: