Healthcare Provider Details

I. General information

NPI: 1679023972
Provider Name (Legal Business Name): JILL MARTIN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 10/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 BROADWAY BLVD NE
ALBUQUERQUE NM
87102-2360
US

IV. Provider business mailing address

707 BROADWAY BLVD NE
ALBUQUERQUE NM
87102-2360
US

V. Phone/Fax

Practice location:
  • Phone: 505-248-2726
  • Fax: 505-248-2723
Mailing address:
  • Phone: 505-248-2726
  • Fax: 505-248-2723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN-69244
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: