Healthcare Provider Details

I. General information

NPI: 1558147041
Provider Name (Legal Business Name): JONATHAN ALLISON MA, LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JONATHAN ROBERT ALLISON MA, LMHC

II. Dates (important events)

Enumeration Date: 08/31/2023
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 TOMASITA ST NE
ALBUQUERQUE NM
87112-5536
US

IV. Provider business mailing address

1026 TOMASITA ST NE
ALBUQUERQUE NM
87112-5536
US

V. Phone/Fax

Practice location:
  • Phone: 505-221-1275
  • Fax:
Mailing address:
  • Phone: 505-221-1275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2022-0854
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: