=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538150719
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANE PRINCE SMITH MSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2005
-----------------------------------------------------
Last Update Date | 06/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2600 MARBLE AVE NE BLDG 2
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87106-2058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-220-7880
-----------------------------------------------------
Fax | 505-288-3573
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2427 133 RINCON LOOP
-----------------------------------------------------
City | TIJERAS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87059-2427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-186-1319
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I 2539
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------