Healthcare Provider Details

I. General information

NPI: 1891514725
Provider Name (Legal Business Name): JACQUELYN SANDOVAL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5850 EUBANK BLVD NE STE B 32
ALBUQUERQUE NM
87111
US

IV. Provider business mailing address

14671 TELEGRAPH ROAD
REDFORD MI
48239
US

V. Phone/Fax

Practice location:
  • Phone: 505-200-2860
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number79545
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number79545
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: