Provider Demographics
NPI:1295035236
Name:STOCKER, JENNIFER A
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:STOCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 36TH ST SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1719
Mailing Address - Country:US
Mailing Address - Phone:810-444-0110
Mailing Address - Fax:
Practice Address - Street 1:4701 MONTGOMERY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1219
Practice Address - Country:US
Practice Address - Phone:505-727-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-0716225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant