Healthcare Provider Details

I. General information

NPI: 1679080360
Provider Name (Legal Business Name): JONATHAN BASKIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2018
Last Update Date: 07/21/2024
Certification Date: 07/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 BROADWAY BLVD NE
ALBUQUERQUE NM
87102-2360
US

IV. Provider business mailing address

405 GREG AVE
SANTA FE NM
87501-1663
US

V. Phone/Fax

Practice location:
  • Phone: 505-267-0701
  • Fax:
Mailing address:
  • Phone: 608-909-1459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-11693
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number130589-121
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9370-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: