Provider Demographics
NPI:1063175214
Name:NOLTE, JACQUELINE M (PTA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:NOLTE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4408 SNOWFLAKE DR NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4266
Mailing Address - Country:US
Mailing Address - Phone:505-697-2691
Mailing Address - Fax:
Practice Address - Street 1:5700 HARPER DR NE STE 110
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3540
Practice Address - Country:US
Practice Address - Phone:505-823-9166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPTA1163225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant