Healthcare Provider Details

I. General information

NPI: 1538150719
Provider Name (Legal Business Name): JANE PRINCE SMITH MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MARBLE AVE NE BLDG 2
ALBUQUERQUE NM
87106-2058
US

IV. Provider business mailing address

PO BOX 2427 133 RINCON LOOP
TIJERAS NM
87059-2427
US

V. Phone/Fax

Practice location:
  • Phone: 505-220-7880
  • Fax: 505-288-3573
Mailing address:
  • Phone: 505-186-1319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI 2539
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: