Healthcare Provider Details

I. General information

NPI: 1013433051
Provider Name (Legal Business Name): JONATHAN R WILLOUGHBY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 LOUISIANA BLVD NE STE H
ALBUQUERQUE NM
87110-3565
US

IV. Provider business mailing address

1800 GEORGIA ST NE
ALBUQUERQUE NM
87110-5903
US

V. Phone/Fax

Practice location:
  • Phone: 505-459-1260
  • Fax:
Mailing address:
  • Phone: 505-459-1260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-10912
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: