Provider Demographics
NPI:1285787986
Name:BORDEGARAY, JANA (OT)
Entity type:Individual
Prefix:
First Name:JANA
Middle Name:
Last Name:BORDEGARAY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4715 MOON ST NE
Mailing Address - Street 2:OSUNA ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2101
Mailing Address - Country:US
Mailing Address - Phone:505-296-4811
Mailing Address - Fax:
Practice Address - Street 1:4715 MOON ST NE
Practice Address - Street 2:OSUNA ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2101
Practice Address - Country:US
Practice Address - Phone:505-296-4811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1099225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ 0745Medicaid