Basic Information
| Provider Information | |||||||||
| NPI: | 1386789824 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENAB | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26666 | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059236770 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6400 PASEO DEL NORTE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871131718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055962100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 46229 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | 2016 | CO | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | MD2020-0385 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 314828 | NY | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.