Provider Demographics
NPI:1063844017
Name:MATHERLY, JENNIFER LYNN (CNM)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:MATHERLY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4351 E LOHMAN AVE STE 401
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8261
Mailing Address - Country:US
Mailing Address - Phone:575-522-4767
Mailing Address - Fax:575-522-3607
Practice Address - Street 1:4351 E LOHMAN AVE STE 401
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8261
Practice Address - Country:US
Practice Address - Phone:575-522-4767
Practice Address - Fax:575-522-3607
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM663367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM42876826Medicaid
NM320603YTYEMedicare PIN