Provider Demographics
NPI:1275867517
Name:PROCTOR, JENNIFER ANN (CNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:933 BRADBURY DR SE STE 2222
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4375
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:505-272-8060
Practice Address - Street 1:7801 ACADEMY RD NE # 2
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-272-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-18
Last Update Date:2023-06-15
Deactivation Date:2018-05-28
Deactivation Code:
Reactivation Date:2018-06-05
Provider Licenses
StateLicense IDTaxonomies
NMCNP-03598363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner