Healthcare Provider Details

I. General information

NPI: 1053990887
Provider Name (Legal Business Name): JON M HAMILTON LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 12/19/2025
Certification Date: 04/07/2021
Deactivation Date: 10/30/2025
Reactivation Date: 12/19/2025

III. Provider practice location address

7232 CANARY LN NE
ALBUQUERQUE NM
87109-6007
US

IV. Provider business mailing address

7232 CANARY LN NE
ALBUQUERQUE NM
87109-6007
US

V. Phone/Fax

Practice location:
  • Phone: 505-900-8392
  • Fax:
Mailing address:
  • Phone: 505-900-8392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCSA0213811
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: