Healthcare Provider Details

I. General information

NPI: 1356284962
Provider Name (Legal Business Name): JACQUELINE JIRON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2026
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 LAMBERTON PL NE
ALBUQUERQUE NM
87107-1617
US

IV. Provider business mailing address

18 TRIBAL ROAD 7
BOSQUE FARMS NM
87068-8003
US

V. Phone/Fax

Practice location:
  • Phone: 505-916-4224
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT2024-0017
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: