Provider Demographics
NPI:1992266274
Name:SQUYRES, JENNIFER REBECCA
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:REBECCA
Last Name:SQUYRES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 BROADWAY BLVD NE STE 401
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2366
Mailing Address - Country:US
Mailing Address - Phone:505-342-5488
Mailing Address - Fax:
Practice Address - Street 1:2112 MAIN ST NE STE C&D
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7097
Practice Address - Country:US
Practice Address - Phone:505-565-1761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program