1659735140 NPI number — MRS. JENNIFER JOHN CHARLEY LADAC

Table of content: MRS. JENNIFER JOHN CHARLEY LADAC (NPI 1659735140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659735140 NPI number — MRS. JENNIFER JOHN CHARLEY LADAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHARLEY
Provider First Name:
JENNIFER
Provider Middle Name:
JOHN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LADAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659735140
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 490
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINEHILL
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87357-0490
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-775-3353
Provider Business Mailing Address Fax Number:
505-775-3630

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 BEHAVIORAL HEALTH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINEHILL
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-775-3353
Provider Business Practice Location Address Fax Number:
505-775-3630
Provider Enumeration Date:
04/11/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  0119271 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com