Provider Demographics
NPI:1659309235
Name:SIMPSON-MANSKE, JENNIFER LYNN (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:SIMPSON-MANSKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 ALTO ST
Mailing Address - Street 2:LA FAMILIA MEDICAL CENTER
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-2406
Mailing Address - Country:US
Mailing Address - Phone:505-982-4425
Mailing Address - Fax:505-995-9643
Practice Address - Street 1:1035 ALTO ST
Practice Address - Street 2:LA FAMILIA MEDICAL CENTER
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-2406
Practice Address - Country:US
Practice Address - Phone:505-982-4425
Practice Address - Fax:505-995-9643
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2007-0744207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ483462Medicaid
NM000Z9318Medicaid
TX8HZ051Medicare ID - Type UnspecifiedHSZ005
TX8HZ021Medicare ID - Type UnspecifiedHSZ002
G61252Medicare UPIN
TX8HZ017Medicare ID - Type UnspecifiedHSZ001
TX8HZ031Medicare ID - Type UnspecifiedHSZ003
NM000Z9318Medicaid
TX8HZ085Medicare ID - Type UnspecifiedHSZ006