Healthcare Provider Details

I. General information

NPI: 1053379321
Provider Name (Legal Business Name): JONATHAN HARTSHORNE M.DIV.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CARLISLE BLVD NE SUITE 129
ALBUQUERQUE NM
87110-1600
US

IV. Provider business mailing address

3200 CARLISLE BLVD NE SUITE 129
ALBUQUERQUE NM
87110-1600
US

V. Phone/Fax

Practice location:
  • Phone: 505-889-4921
  • Fax:
Mailing address:
  • Phone: 505-889-4921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5699
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: