Healthcare Provider Details

I. General information

NPI: 1184749848
Provider Name (Legal Business Name): JENNIFER M EDWARDS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MENAUL BLVD NE
ALBUQUERQUE NM
87107-1614
US

IV. Provider business mailing address

9019 VISTAS DR NE
ALBUQUERQUE NM
87113-2128
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-5501
  • Fax:
Mailing address:
  • Phone: 505-797-0599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number2397
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: