Provider Demographics
NPI:1477022895
Name:SWARTZENTRUBER, JESSIE ELLEN (MOTR/L)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:ELLEN
Last Name:SWARTZENTRUBER
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 14TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87104-1212
Mailing Address - Country:US
Mailing Address - Phone:505-331-6940
Mailing Address - Fax:
Practice Address - Street 1:201 14TH ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-1212
Practice Address - Country:US
Practice Address - Phone:505-331-6940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOT3044225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist