=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528932365
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA ROSE MARTINEZ FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2025
-----------------------------------------------------
Last Update Date | 10/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 MORA VALLEY CLINIC RD
-----------------------------------------------------
City | MORA
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87732-2202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-387-2201
-----------------------------------------------------
Fax | 575-387-9006
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87715-0002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-387-2201
-----------------------------------------------------
Fax | 575-387-9006
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | 54060
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------