Healthcare Provider Details

I. General information

NPI: 1033733043
Provider Name (Legal Business Name): FOREST NEAL JARNAGIN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 NATALIE AVE NE
ALBUQUERQUE NM
87110-1308
US

IV. Provider business mailing address

6400 NATALIE AVE NE
ALBUQUERQUE NM
87110-1308
US

V. Phone/Fax

Practice location:
  • Phone: 505-379-3216
  • Fax:
Mailing address:
  • Phone: 505-379-3216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT898
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: