Healthcare Provider Details

I. General information

NPI: 1245330786
Provider Name (Legal Business Name): JERRY ROBERT MARSHALL PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4930 MCLEOD RD NE
ALBUQUERQUE NM
87109-2118
US

IV. Provider business mailing address

7508 MCNERNEY AVE NE
ALBUQUERQUE NM
87110-2224
US

V. Phone/Fax

Practice location:
  • Phone: 505-884-2032
  • Fax:
Mailing address:
  • Phone: 505-830-9030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2024
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: