Healthcare Provider Details

I. General information

NPI: 1619213881
Provider Name (Legal Business Name): JESSICA RACHELLE CONKLIN PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2012
Last Update Date: 12/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1036 CASA ROJA PL NW
ALBUQUERQUE NM
87120-6587
US

IV. Provider business mailing address

1036 CASA ROJA PL NW
ALBUQUERQUE NM
87120-6587
US

V. Phone/Fax

Practice location:
  • Phone: 505-320-3764
  • Fax:
Mailing address:
  • Phone: 505-320-3764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License NumberRP00007698
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: