Healthcare Provider Details

I. General information

NPI: 1780430835
Provider Name (Legal Business Name): JENNIFER SWANK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2024
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 LOBO CANYON RD
GRANTS NM
87020-2349
US

IV. Provider business mailing address

PO BOX 803
GRANTS NM
87020-0803
US

V. Phone/Fax

Practice location:
  • Phone: 505-475-7449
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT9581
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: