Healthcare Provider Details

I. General information

NPI: 1366985616
Provider Name (Legal Business Name): JENNA BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2016
Last Update Date: 11/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 1ST ST NW
ALBUQUERQUE NM
87102-1529
US

IV. Provider business mailing address

PO BOX 23691
SANTA FE NM
87502-3691
US

V. Phone/Fax

Practice location:
  • Phone: 505-766-5197
  • Fax: 505-766-6945
Mailing address:
  • Phone: 505-303-8994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1167
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: