Provider Demographics
NPI:1568762805
Name:AYALA, JACK ANTHONY I
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:ANTHONY
Last Name:AYALA
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-1414
Mailing Address - Country:US
Mailing Address - Phone:505-212-7363
Mailing Address - Fax:
Practice Address - Street 1:1225 4TH ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1414
Practice Address - Country:US
Practice Address - Phone:505-212-7363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator