Provider Demographics
NPI:1619002656
Name:MERRILL, JANE E (MS, PT)
Entity type:Individual
Prefix:MS
First Name:JANE
Middle Name:E
Last Name:MERRILL
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 LAFAYETTE PL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2140
Mailing Address - Country:US
Mailing Address - Phone:505-232-7889
Mailing Address - Fax:
Practice Address - Street 1:230 TRUMAN ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1333
Practice Address - Country:US
Practice Address - Phone:505-268-9506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM12102251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM68339782Medicaid
NM1210OtherPT LICENSE NUMBER