Provider Demographics
NPI:1740561216
Name:HERNANDEZ, JENNIFER GL (RN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:GL
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 SIPAPU ST
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6489
Mailing Address - Country:US
Mailing Address - Phone:575-758-5857
Mailing Address - Fax:
Practice Address - Street 1:413 SIPAPU ST
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6489
Practice Address - Country:US
Practice Address - Phone:575-758-5857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NML19428163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)