Healthcare Provider Details

I. General information

NPI: 1295784353
Provider Name (Legal Business Name): JONATHAN TRIMBLE MACK EDM, LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 03/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7109 PROSPECT PL NE
ALBUQUERQUE NM
87110-4313
US

IV. Provider business mailing address

PO BOX 1613
PERALTA NM
87042-1613
US

V. Phone/Fax

Practice location:
  • Phone: 505-796-4004
  • Fax: 505-830-3264
Mailing address:
  • Phone: 505-796-4004
  • Fax: 505-866-9278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0086461
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: