Healthcare Provider Details

I. General information

NPI: 1245851500
Provider Name (Legal Business Name): JILL D MCCLEARY LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2020
Last Update Date: 04/28/2020
Certification Date: 04/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 UNIVERSITY BLVD NE
ALBUQUERQUE NM
87102-1716
US

IV. Provider business mailing address

601 NATHAN ST SE
ALBUQUERQUE NM
87123-3815
US

V. Phone/Fax

Practice location:
  • Phone: 505-238-4319
  • Fax:
Mailing address:
  • Phone: 505-238-4319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number8009
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: