Healthcare Provider Details

I. General information

NPI: 1477386852
Provider Name (Legal Business Name): JUMPSTART, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2024
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 WYOMING BLVD NE M-4 ,#406
ALBUQUERQUE NM
87113
US

V. Phone/Fax

Practice location:
  • Phone: 505-633-8500
  • Fax:
Mailing address:
  • Phone: 505-828-3837
  • Fax: 877-828-1550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

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