Individual
MS. JENNIFER LEA LEA CLAYCOMB
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
500 NORTH MUNDO, DULCE, NM 87528-0187
(505) 759-3291
(505) 759-3532
Mailing address
PO BOX 187, DULCE, NM 87528-0187
(505) 759-3291
(505) 759-3532
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
2005019602
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000K3526
—
NM
05
—
01929259
—
NM
01
—
8HN171
PROVIDER MEDICARE #
NM
01
—
HSZ196
MEDICARE PART B
NM
Enumeration date
09/06/2006
Last updated
05/25/2011
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