Healthcare Provider Details

I. General information

NPI: 1659200780
Provider Name (Legal Business Name): JONATHAN ERIC HURTEAU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 CAMINO DEL MEDIO
SAN CRISTOBAL NM
87564
US

IV. Provider business mailing address

PO BOX 133
SAN CRISTOBAL NM
87564-0133
US

V. Phone/Fax

Practice location:
  • Phone: 818-941-2361
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: