Healthcare Provider Details

I. General information

NPI: 1982008256
Provider Name (Legal Business Name): JESSICA LYN STEM ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2014
Last Update Date: 10/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 S CHURCH AVE
AZTEC NM
87410-2107
US

IV. Provider business mailing address

320 S CHURCH AVE
AZTEC NM
87410-2107
US

V. Phone/Fax

Practice location:
  • Phone: 505-486-6412
  • Fax:
Mailing address:
  • Phone: 505-486-6412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number361
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: