Provider Demographics
NPI:1871911545
Name:BRANDENBURG, JACQUELYN (DO)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:
Last Name:BRANDENBURG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 BRADBURY DR SE
Mailing Address - Street 2:SUITE 2222
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4374
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:505-272-8060
Practice Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Practice Address - Street 2:MSC 10-6000
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-6487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR02-2014390200000X
NMDO2021-0049208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program