Provider Demographics
NPI:1972113660
Name:GOMEZ, JENNA MARIE
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:GUTIERREZ GOMEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:620 LOMAS BLVD NW # 2080
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2080
Mailing Address - Country:US
Mailing Address - Phone:505-247-1701
Mailing Address - Fax:505-247-1704
Practice Address - Street 1:620 LOMAS BLVD NW # 2080
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2080
Practice Address - Country:US
Practice Address - Phone:505-247-1701
Practice Address - Fax:505-247-1704
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCF7151235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist