MEDICARE: MR. JONATHAN TRIMBLE MACK EDM, LPCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	0086461	NM

General Provider Information

NPI Number	:	1295784353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JONATHAN TRIMBLE MACK EDM, LPCC

Provider Business Mailing Address
First Line	:	PO BOX 1613
Second Line	:
City	:	PERALTA
State	:	NM
Zip	:	87042-1613
Country	:	US
Telephone Number	:	505-796-4004
Fax Number	:	505-866-9278

Provider Business Practice Location Address
First Line	:	7109 PROSPECT PL NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-4313
Country	:	US
Telephone Number	:	505-796-4004
Fax Number	:	505-830-3264

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	03/08/2010

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