Provider Demographics
NPI:1982292561
Name:NEWMAN, JACQUE (CO)
Entity Type:Individual
Prefix:
First Name:JACQUE
Middle Name:
Last Name:NEWMAN
Suffix:
Gender:F
Credentials:CO
Other - Prefix:
Other - First Name:JACQUE
Other - Middle Name:
Other - Last Name:NEWMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CO
Mailing Address - Street 1:221 STATE HIGHWAY 165 STE F
Mailing Address - Street 2:
Mailing Address - City:PLACITAS
Mailing Address - State:NM
Mailing Address - Zip Code:87043-9514
Mailing Address - Country:US
Mailing Address - Phone:505-437-3900
Mailing Address - Fax:505-437-3906
Practice Address - Street 1:221 STATE HIGHWAY 165 STE F
Practice Address - Street 2:
Practice Address - City:PLACITAS
Practice Address - State:NM
Practice Address - Zip Code:87043-9514
Practice Address - Country:US
Practice Address - Phone:505-353-2484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM06551769Medicaid