Healthcare Provider Details

I. General information

NPI: 1255006565
Provider Name (Legal Business Name): BRANDON JOPEK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 GRANDE BLVD SE
RIO RANCHO NM
87124-1799
US

IV. Provider business mailing address

1740 GRANDE BLVD SE
RIO RANCHO NM
87124-1799
US

V. Phone/Fax

Practice location:
  • Phone: 505-979-0715
  • Fax:
Mailing address:
  • Phone: 505-979-0715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCMH0219551
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: