Healthcare Provider Details

I. General information

NPI: 1609433804
Provider Name (Legal Business Name): JACQUELINE COLLETTE JOHNSON LMT, NTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACQUELINE COLLETTE PAYTIAMO

II. Dates (important events)

Enumeration Date: 05/22/2019
Last Update Date: 05/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 MADEIRA DR SE
ALBUQUERQUE NM
87108-3614
US

IV. Provider business mailing address

612 MADEIRA DR SE
ALBUQUERQUE NM
87108-3614
US

V. Phone/Fax

Practice location:
  • Phone: 505-263-7882
  • Fax:
Mailing address:
  • Phone: 505-263-7882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number9685
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: