Healthcare Provider Details

I. General information

NPI: 1780405035
Provider Name (Legal Business Name): AUDREY JESSUP CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 DON PASQUAL RD NW
LOS LUNAS NM
87031-8841
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-873-7400
  • Fax:
Mailing address:
  • Phone: 505-272-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number892
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: