Healthcare Provider Details

I. General information

NPI: 1013296912
Provider Name (Legal Business Name): JENNIFER FOWLER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2011
Last Update Date: 08/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4363 VILLAGE LOOP
SANTA FE NM
87507-1834
US

IV. Provider business mailing address

4363 VILLAGE LOOP
SANTA FE NM
87507-1834
US

V. Phone/Fax

Practice location:
  • Phone: 505-660-9110
  • Fax:
Mailing address:
  • Phone: 505-660-9110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number5906
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: