Basic Information
| Provider Information | |||||||||
| NPI: | 1578655254 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACH | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MARY | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 CEDAR ST SE | ||||||||
| Address2: | STE. 5640 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058436168 | ||||||||
| FaxNumber: | 5052479743 | ||||||||
| Practice Location | |||||||||
| Address1: | 4640 JEFFERSON LN NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871092116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058436168 | ||||||||
| FaxNumber: | 5053383456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 01/12/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 592 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 93051531 | 05 | NM | MEDICAID |