Healthcare Provider Details

I. General information

NPI: 1184947004
Provider Name (Legal Business Name): JENNIFER CRISTEN PENA SMITH LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2010
Last Update Date: 03/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 HERMOSA DR NE
ALBUQUERQUE NM
87108-1023
US

IV. Provider business mailing address

201 HERMOSA DR NE
ALBUQUERQUE NM
87108-1023
US

V. Phone/Fax

Practice location:
  • Phone: 505-803-5353
  • Fax:
Mailing address:
  • Phone: 505-803-5353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number6541
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: