Healthcare Provider Details

I. General information

NPI: 1003368150
Provider Name (Legal Business Name): JENNIFER MACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5904 HOLLY AVE NE
ALBUQUERQUE NM
87113-2472
US

IV. Provider business mailing address

9201 MONTGOMERY BLVD NE STE 201
ALBUQUERQUE NM
87111-2467
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-2505
  • Fax: 505-298-2985
Mailing address:
  • Phone: 505-298-2505
  • Fax: 505-298-2985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number85353
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: