MEDICARE: JESSE JAMES ROBINSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	RP00009537	NM

General Provider Information

NPI Number	:	1134894207
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE JAMES ROBINSON

Provider Business Mailing Address
First Line	:	2800 VAIL AVE SE UNIT 257
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106-3161
Country	:	US
Telephone Number	:	573-247-5276
Fax Number	:

Provider Business Practice Location Address
First Line	:	31 SHERWOOD BLVD
Second Line	:
City	:	WHITE ROCK
State	:	NM
Zip	:	87547-3730
Country	:	US
Telephone Number	:	505-672-9457
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2021
Last Update Date	:	08/11/2021

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