Provider Demographics
NPI:1144323353
Name:CLAYCOMB, JENNIFER LEA LEA (MD)
Entity type:Individual
Prefix:MS
First Name:JENNIFER LEA
Middle Name:LEA
Last Name:CLAYCOMB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528-0187
Mailing Address - Country:US
Mailing Address - Phone:505-759-3291
Mailing Address - Fax:505-759-3532
Practice Address - Street 1:500 NORTH MUNDO
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528-0187
Practice Address - Country:US
Practice Address - Phone:505-759-3291
Practice Address - Fax:505-759-3532
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005019602207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000K3526Medicaid
NM01929259Medicaid
NMHSZ196OtherMEDICARE PART B
NM8HN171OtherPROVIDER MEDICARE #
NM320057Medicare Oscar/Certification