MEDICARE: JENNIFER IVEY M.P.T.

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	225100000X	Physical Therapist	9141	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3391	OTHER	NM	STATE LICENSE

General Provider Information

NPI Number	:	1225069107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER IVEY M.P.T.

Provider Business Mailing Address
First Line	:	1225 8TH ST NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87102-1249
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	505 ELM ST NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87102-2500
Country	:	US
Telephone Number	:	505-727-4725
Fax Number	:	505-727-4875

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

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	07/08/2007

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