Healthcare Provider Details

I. General information

NPI: 1225206105
Provider Name (Legal Business Name): JUMPSTART, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 WASHINGTON ST NE STE A1
ALBUQUERQUE NM
87113-1861
US

IV. Provider business mailing address

8100 M4 WYOMING NE #406
ALBUQUERQUE NM
87113-6615
US

V. Phone/Fax

Practice location:
  • Phone: 505-828-3837
  • Fax: 877-828-1550
Mailing address:
  • Phone: 505-828-3837
  • Fax: 877-182-8550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number0877
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: BRIAN LOPEZ
Title or Position: MANAGING MEMBER
Credential: PHD
Phone: 505-828-3837