Healthcare Provider Details

I. General information

NPI: 1891637963
Provider Name (Legal Business Name): SHATOYA F JACOB
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2026
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE # 128
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

1501 SAN PEDRO DR SE # 128
ALBUQUERQUE NM
87108-5153
US

V. Phone/Fax

Practice location:
  • Phone: 505-800-1874
  • Fax: 505-800-1874
Mailing address:
  • Phone: 505-800-1874
  • Fax: 505-800-1874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number100756391
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: